key: cord-0869137-g67o6tbc authors: Underhill, Craig; Parente, Phillip; McArthur, Grant; Haydon, Andrew; McLachlan, Sue‐Anne; Wong, Zee Wan; Segelov, Eva title: Towards new models of cancer care in Australia: lessons from Victoria's response to the COVID‐19 pandemic date: 2020-09-20 journal: Intern Med J DOI: 10.1111/imj.15012 sha: df6a5cc22fd86db92e8e01af214230e4d3aca097 doc_id: 869137 cord_uid: g67o6tbc In response to the COVID‐19 pandemic, the Department of Health and Human Services Victoria (DHHS), the Monash Partners Comprehensive Cancer Consortium (MPCCC) and Victorian Comprehensive Cancer Centre (VCCC) pooled their combined infrastructure to establish the Victorian COVID‐19 Cancer Network (VCCN) backed by a Taskforce of expert members. In a few short months, this state‐wide clinical network implemented a number of new models of care including clinics to manage acutely presenting cancer patients away from emergency departments, chemotherapy in the home, telehealth models and addressing sustainability of clinical trials. The COVID-19 pandemic response in Australia has involved governments, health services and individual health providers preparing for a worst-case scenario. The expectation was that 'usual care' would be impacted, to varying degrees, according to the rate of community transmission of SARS-COV2. For cancer services, there was concern from patients and clinicians on two fronts: care of cancer patients who contracted COVID-19 and the continuation of standard care in uninfected patients. Guidelines on treatment modifications were rapidly developed based on expert opinion in an evidence-free zone. 1 In the cancer sector, we have effectively been operating on a 'war-footing' for many years. Politicians speak of the 'war' on cancer; the WHO first warned in the 1990s of the coming 'cancer pandemic' and a 'tsunami' of cases, which is now upon us as the global population ages and more effective treatments are found. 2 Although mortality rates have improved, cancer remains a leading cause of death in Australia; it is the disease with the highest burden and has substantial social and economic impacts. 3, 4 In Victoria in 2018, 35 203 people were diagnosed with cancer and 11 134 people died, far in excess of those likely now to succumb to COVID-19. 5 The cancer sector, drawing together existing networks and informal collaborations, was able to respond nimbly to the COVID-19 threat, the legacy of which should allow lasting positive change. Whilst some similar work has occurred in other jurisdictions, we report state-wide cancer sector responses in Victoria. With the backing of Department of Health and Human Services Victoria (DHHS), the Monash Partners Comprehensive Cancer Consortium (MPCCC) and Victorian Comprehensive Cancer Centre (VCCC) pooled their combined infrastructure to establish the Victorian COVID-19 Cancer Network (VCCN) backed by a Taskforce of expert members. 6 The VCCN also partnered with Cancer Council Victoria to focus specifically on support and communications needs of patients. The VCCN uses digital tools such as videoconferencing, online survey tools and is centred around a dedicated Slack communication platform to provide a forum for discussion, data sharing and expert consensus (Table 1) . Major areas of concern were identified, and representative subcommittees chaired by key opinion leaders were established, each supported by a project manager. (Table 2 ). Participation is voluntary; within 2 weeks, around 700 multidisciplinary cancer clinicians and stakeholders had subscribed. Representatives from both public and private institutions across the state were included. Whilst yet to be formally evaluated, these groups appear to be highly successful in facilitating communication and collaboration across the cancer sector. They have shared existing policies, guidelines and models of care and developed new paradigms for use across the state, some of which are discussed below. The COVID-19 pandemic response has fast-tracked new models of care, driven by a perceived need to keep immunosuppressed patients out of emergency departments and away from hospitals as much as possible. These new models include nurse-led assessment clinics within oncology outpatient units, to triage and manage immunocompromised patients within established criteria, to screen patients for COVID-risk factors and directly admit or discharge as appropriate. The Symptom and Urgent Review Clinic model has been previously piloted in some Victorian cancer centres and demonstrated to be cost-effective. 7 Established clinics are having their hours extended and scope and staffing enhanced, providing an alternative pathway for review and screening prior to day centre treatments. This model is suited to the assessment of patients with many other chronic diseases. The Victorian Department of Health and Human Services brought forward release of its recently commissioned Home-Based Cancer Care Framework and Toolkit, being developed in response to the increased demand for day oncology services. 8 In the context of COVID-19, the use of Hospital in the Home and other services for cancer treatment is highly desirable, where safe to do so. Many new cancer therapies such as immunotherapy are very suitable for this; development of alternative formulations (e.g. subcutaneous) of common anticancer drugs has also facilitated this. This model is however limited by some safety, indemnity and resourcing constraints. Particularly for outer metropolitan and regional areas, distance impacts on the productivity of this model, coldchain issues are more pronounced, and an emergency response is not always close by. Some have also advocated the establishment of community centres for low-risk cancer care procedures, along the lines of community dialysis centres, offering an alternative to home-based care. 9 Closest to home referrals for cancer care At times referral pathways between services can be complex and maybe based on historical relationships. There is a balance between convenience and safety, but sometimes patients or clinicians are not aware of services that would allow care much closer to their home. The expansion of specialised oncologists based in rural and regional centres has not yet overcome longstanding biases that treatment may be better within a large city. However, with travel restrictions and general fear of the population of COVID-19, outer-lying cancer centres reported a significant efflux of patients from more central services (P. Parente et al., pers. comm., 2020). Concerns about the impact of COVID-19 illness or the need for isolation of the Victorian specialised healthcare workforce drove a rapid state-wide crossaccreditation process. A survey of the VCCN Clinical Leads showed that 90% supported a database of skilled staff across both public and private institutions, with 100% support to protect rural sites (P. Parente, pers. comm.). To date, although workforce reallocations requests have been made, no actual redistributions have occurred. Other examples of shared policies include: (i) pathways for how best to manage febrile cancer patients. There is a perceived need to consider how best to manage immunosuppressed patients presenting with fever, and without exposing staff and patients within inpatient units of the risk of exposure to COVID-19. (ii) Clinical Ethics committees, which in circumstances of a pandemic surge and resource constraint, could help provide a framework and appropriate mechanisms to assist patients, families and clinicians. Already established in a limited number of health services, clinical ethics services could address these challenging issues in a responsive, transparent and consistent manner during and beyond the COVID crisis. 10 The COVID-19 pandemic has catalysed a major shift to the use of telehealth across the spectrum of clinical practice. This was widely and early adopted by cancer services. The VCCN has been active in providing and promoting guides for patients, administration and clinicians for successful implementation of cancer telehealth. Many clinicians have called for this model to continue after the pandemic in certain circumstances and a formal evaluation of uptake and barriers is planned. The use of telehealth to conduct clinical trials (so called 'tele-trials') has been pioneered by the cancer sector. 11 The importance of continuing clinical trials for cancer was paramount during COVID-19, where patients were not deemed at excess risk from trial participation and were seen to be at a disadvantage without a trial option. Changes have included remote monitoring and new trial start-up, home delivery of trial medication and direct data entry from redesigned electronic case report forms. However, there is a need for development and implementation of national standards to achieve a future state of virtual trial management. Despite improvements in cancer outcomes, pockets of disparity remain, such as a 4% gap in 5-year outcomes for regional Victorians, which translates into approximately 500 excess deaths each year. 5 Inequity exists in areas of lower socioeconomic status and indigenous, refugee, elderly and Culturally and Linguistically Diverse communities, almost certainly related to insufficient total investment, as well as maldistribution of resources. 12 We call for a renewed effort by our national and state governments to improve cancer outcomes. Just as Australia is leading the world in its response to COVID-19, equally it should lead the world in improving cancer control for all its population. This requires an ongoing rational, needs-based investment where infrastructure and resources are lacking. It requires better investment and access to research and clinical trials, widespread access to tumour genomic testing and other technologies, building a world class training system and working with primary care in better prevention, screening and shared care. Telehealth is an important tool to drive improvements. The rapid changes that have occurred in response to the threat of a pandemic demonstrate what can be achieved at a time of need. We hope this is a call to lasting changes in cancer care provision. We call on a refocussed effort to overcome the biggest health threat to our communities in the 21st century, the ongoing epidemic of cancer. Practical considerations for treating cancer patients in the COVID-19 pandemic World Health Organization (WHO). The World Health Report 1999: making a difference Australian Burden of Disease Study: Impact and Causes of Illness and Death in Australia Australian Institute of Health and Welfare. Cancer in Australia Melbourne: Cancer Council Victoria The Victorian COVID-19 Cancer Network Economic assessment of a new model of care to support patients with cancer experiencing cancer-and treatmentrelated toxicities Department of Health and Human Services Victoria. Home based cancer care framework and toolkit. Melbourne: Department of Health and Human Services COVID-19: impact on cancer workforce and delivery of care An ethics framework for making resource allocations decisions within clinical care: responding to COVID-19 Australasian Tele-trial Model: access to clinical trials close to home using tele-health Version Australian Institute of Health and Welfare. Australia's health Australia's Health Series No. 16. AUS 221. Canberra: AIHW