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

Cancer Australia’s conceptual framework provides guidance for optimal management of cancer during the COVID-19 pandemic, and similar pandemics in the future.

Cancer care during a pandemic

With successive infection waves and spread of more infectious variants of coronavirus SARS-CoV-2, the COVID-19 pandemic continues to have major impacts on healthcare.

To achieve best outcomes for cancer patients during a pandemic, efforts to minimise the increased risk of severe pandemic infection must be carefully balanced against unintended adverse impacts of the pandemic on cancer care, with consideration to available health system capacity.

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

In May 2020, early in the pandemic, Cancer Australia published a conceptual framework for the management of cancer during a pandemic as a thought piece for optimal cancer care during the COVID-19 pandemic. It provided a framework for system-wide approaches to cancer management and opportunities for decision-making about modifications to cancer care, in accordance with the principles of the Optimal Care Pathways for people with cancer.

The ongoing progression of the pandemic has provided an opportunity to examine the evidence base and reflect on learnings from the COVID-19 pandemic and further update the conceptual framework for cancer care.

Cancer Australia’s updated Conceptual framework for cancer care during a pandemic incorporating evidence from the COVID-19 pandemic provides guidance on how to continue cancer care across the cancer pathway, in the face of challenges to health systems, while minimising infection risk for cancer patients. The evidence supports the continuation of cancer care wherever possible during a pandemic in order to achieve the best outcomes for cancer patients and the community, and to minimise the adverse impacts of the pandemic on cancer care.

At each step on the cancer care continuum, decisions on cancer care should be based on consideration of health system capacity and capacity for cancer care delivery, in relation to the progression of the pandemic and pandemic infection control. The conceptual framework provides guidance in a matrix structure, across the cancer care continuum (from prevention and early detection through to survivorship and end-of-life care), for the each of the different phases of a pandemic (acute and recovery phases).

The guidance in the conceptual framework is supported by evidence from the COVID-19 pandemic and guidance, recommendations, and position statements from peak cancer care organisations on cancer care during the COVID-19 pandemic.

The updated conceptual framework provides an evidence-based ‘toolkit’ for cancer care during the current COVID-19 pandemic and future similar pandemics. It reflects changing health system capacity and is consolidated by consideration of best-practice principles for optimal cancer care. The framework provides a planning resource for stakeholders including health services and policy-makers.

Emerging evidence and data will continue to inform the evolution of the framework to guide ongoing cancer care during this, and future, pandemics.

Read A conceptual framework for cancer care during a pandemic incorporating evidence from the COVID-19 pandemic.

Cancer care across the COVID-19 pandemic curves

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

figure1covid19

Figure 1 – Pandemic phases in relation to health system capacity

Health system capacity represents the capacity of the health system to treat patients, based on factors including (but not limited to) availability of hospital supplies, healthcare worker resources, personal protective equipment (PPE), intensive care unit (ICU) bed and ventilator capacity, medications (including for pandemic infection treatment and oncology treatment), and access to pathology and imaging services. Health system capacity is shown as a band with dashed lines to represent its range during a pandemic because of multiple components that could increase or decrease at any time.
The blue line indicates an uncontrolled outbreak with rapidly increasing numbers where health system capacity may be exceeded.
The green line indicates a mitigated scenario with a slower rate of transmission.

Acute and recovery phases, incorporating both the pandemic progression and health system capacity, based on phases described by the American College of Surgeons, are indicated as follows:

Acute phase I: Semi-urgent setting. Few pandemic infection patients and numbers not rapidly escalating, demand within health system capacity; hospital supplies and healthcare staff resources are not exhausted; hospitals still have ICU capacity.
Acute phase II: Urgent setting. Rapidly escalating numbers of pandemic infection patients, approaching limits of health system capacity; hospital supplies and healthcare staff resources are limited due to factors such as redeployment to pandemic-related activities; ICU capacity increasingly limited.
Acute phase III: Emergency setting. High numbers of pandemic infection patients, health system capacity exceeded; hospital supplies and healthcare staff resources are overwhelmed or exhausted by pandemic-related activities with no spare capacity; no spare ICU capacity.
Recovery phases. Past the peak of pandemic infection with fewer new daily cases, health system capacity not exceeded; hospital supplies and healthcare staff resources are more available, including hospital and ICU beds, healthy staff, PPE, and critical testing.

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 demand on the health system due to COVID-19, 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 were augmented to support optimal cancer care during the COVID-19 pandemic.

The guidance and evidence identified in the current review support the importance and relevance of these principles during a pandemic. Provision of safe and quality care by minimising the risk of pandemic infection for cancer patients and healthcare staff is highly relevant and a key consideration for optimal cancer care during a pandemic. Similarly, during a pandemic, patient-centred and multidisciplinary care are of great importance for individualised treatment and treatment decisions; care coordination and communication are essential, especially for treatment planning and in the context of changes in cancer treatment; and supportive care can assist with the psychosocial impacts of a pandemic. New opportunities for research and clinical trials, such those based on large registries, have become available during the COVID-19 pandemic.

To read about the application of the Principles of optimal cancer care in a pandemic, visit Conceptual framework for cancer care during a pandemic incorporating evidence from 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.

Click to open image below or download the PDF version.

To view the detailed framework for cancer management mapped to pandemic phases across the continuum of care, visit A conceptual framework for cancer care during a pandemic incorporating evidence from the COVID-19 pandemic.