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ORIGINAL ARTICLE
Year : 2021  |  Volume : 17  |  Issue : 2  |  Page : 547-550

Impact of the COVID-19 pandemic on health care activities at a Uruguayan mastology unit


Department of Clinical Oncology, Hospital de Clínicas “Dr. Manuel Quintela”, School of Medicine, University of Uruguay, Montevideo, Uruguay

Date of Submission25-Nov-2020
Date of Acceptance03-Jan-2021
Date of Web Publication11-Jun-2021

Correspondence Address:
Cecilia Castillo
Hospital de Clinicas, Av Italia S/N. CP 11600, Montevideo
Uruguay
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_1689_20

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 > Abstract 


Purpose: Health emergency due to COVID-19 started in Uruguay on March 13, 2020; our mastology unit tried to ensure adequate oncological care, and protect patients from the virus infection and complications.
Objective: To assess the health care activities in the “peak” of the pandemic during 3 months.
Materials and Methods: we collected data from the electronic health record.
Results: There were a total of 293 medical appointments from 131 patients (221 face-to-face), that decreased by 16.7% compared to the same period in 2019 (352 appointments). The medical appointments were scheduled to evaluate the continuity of systemic treatment or modifications (95 patients; 72.5%), follow-up (17; 12.9%), first-time consultation (12; 9.1%), and assess paraclinical studies (7; 5.3%). The patients were on hormone therapy (81 patients; 74%), chemotherapy (CT) (21; 19%), and anti-HER2 therapies (9; 8%). New twenty treatments were initiated. Of the 14 patients that were on adjuvant/neoadjuvant CT, 9 (64.3%) continued with the same regimen with the addition of prophylactic granulocyte-colony-stimulating factors (G-CSF), and 5 (35.7%), who were receiving weekly paclitaxel, continued the treatment with no changes. Of the seven patients that were on palliative CT, 2 (28.5%) continued the treatment with the addition of G-CSF, 3 (42.8%) continued with weekly capecitabine or paclitaxel with no treatment changes, and 2 (28.5%) changed their treatment regimen (a less myelosuppressive regimen was selected for one and due to progression of the disease in the other patient). The ninety patients who were receiving adjuvant, neoadjuvant, or palliative criteria hormone therapy and/or anti-HER2 therapies, continued the treatment with no changes.
Conclusions: The evidence suggests that, although medical appointments decreased by approximately 17%, we could maintain healthcare activities, continued most of the treatments while the most modified was CT with G-CSF to avoid myelosuppression.

Keywords: Breast cancer, COVID 19, pandemic, systemic treatment


How to cite this article:
Castillo C, Camejo N, Amarillo D, Rodriguez F, Vitureira F, Krygier G, Delgado L. Impact of the COVID-19 pandemic on health care activities at a Uruguayan mastology unit. J Can Res Ther 2021;17:547-50

How to cite this URL:
Castillo C, Camejo N, Amarillo D, Rodriguez F, Vitureira F, Krygier G, Delgado L. Impact of the COVID-19 pandemic on health care activities at a Uruguayan mastology unit. J Can Res Ther [serial online] 2021 [cited 2021 Sep 23];17:547-50. Available from: https://www.cancerjournal.net/text.asp?2021/17/2/547/318108




 > Purpose Top


The Uruguayan government declared a national health emergency due to COVID-19 on Friday, March 13, 2020, urging the population to be confined to their homes to slow down the progression of the epidemic. This resulted in important changes in the organization of health services, and impacted the health care of several diseases including cancer. Cancer is a significant health problem in Uruguay. It is the second-highest cause of death after cardiovascular diseases, causing almost a quarter (24.6%) of all deaths registered in the country per year. Almost 16,179 new cases are registered annually, and more than 7995 Uruguayans die from cancer.[1],[2] As seen globally, breast cancer (BC) is the most common cancer in women in Uruguay, and is also the main cause of death from cancer. About 1926 new cases are registered every year, and about 670 women die as a result of this disease.

The objectives of the health care activities provided to patients of BC attending the Mastology Unit of the School of Medicine (Unidad Docente Asistencial de Mastología [UDAM]) in the context of the COVID-19 pandemic were to ensure adequate oncological care. Despite the pandemic, it was important for patients to receive care to achieve the same rates of curability (localized cancers) and survival (advanced cancers) as before the pandemic, and to protect patients from the virus infection, and from serious or fatal complications that could result from a possible state of immunosuppression.

To this end, the Department of Clinical Oncology of the Clinical Hospital developed recommendations for the care of cancer patients and the management of BC patients (diagnosis and treatment) in the context of the epidemic.[3] These recommendations were based on those developed by the government health authority, the University of the Republic (Universidad de la República-UdelaR), national and international scientific societies, as well as published reports, and were modified according to the progression of the pandemic and the available scientific evidence on COVID-19 in cancer patients. To the best of our knowledge, there is no available information in Uruguay about the impact of the pandemic on patients diagnosed with BC. Hence, we conducted a study to assesses the care provided to these patients during the period considered as the “peak” of the health emergency. This study aims at providing useful information to the health professionals and health authorities (National Emergency System).

Objective

To assess the health care activities provided by the Department of Clinical Oncology of the UDAM during the period considered as the “peak” of the pandemic, from its beginning to June 30, 2020.


 > Materials and Methods Top


This is an observational retrospective study that included patients diagnosed with BC who were attended to, at the Department of Clinical Oncology of UDAM of the Clinical Hospital between March 13 and June 30, 2020. We collected data from the electronic clinical record system called Oncology Electronic Health Record (Historia Clínica Electrónica Oncológica [HCEO]) during the study period. The differences with respect to the same period in 2019 in terms of the volume of health care activities were quantified for assessing parameters such as the number of medical appointments and treatments provided. Telephonic triage of patients scheduled for outpatient medical appointments was implemented. The paraclinical findings were reviewed in all appointments (if available) and the on-site appointments were coordinated, when necessary, based on the results and the health situation.

Moreover, changes to the treatments were analyzed. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.


 > Results Top


There were 293 medical appointments (221 in person and 72 by telephone) through which a total of 131 patients with a median age of 60 years (ranging from 29 to 101 years) were attended to. The medical appointments were scheduled to assess the continuity of the systemic treatment and treatment modifications (95 patients; 72.5%), for disease control (17; 12.9%), for first-time consultation (12; 9.1%), and to assess paraclinical studies as tomography, bone scintigraphy, etc., (7; 5.3%). The day hospital coordinated 115 chemotherapy (CT) and/or anti-HER2 treatments.

During the aforementioned period, twenty patients were initiated on treatment; 14 with hormonal therapy (HT) and six with chemotherapy (CT). Of all patients undergoing treatment, 81 (74%) were on HT, 21 (19%) were on CT, and 9 (8%) were on anti-HER2 therapies. Of all patients on CT, 14 (66.6%) patients who were on adjuvant/neoadjuvant CT, 9 (64.3%) continued with the same regimen with the addition of prophylactic granulocyte colony stimulating factors (G-CSF), and 5 (35.7%), who were on weekly paclitaxel therapy, continued the treatment with no changes. The remaining seven patients (33.3%) were on palliative chemotherapy, of which 2 (28.5%) continued the regimen with the addition of G-CSF, 3 (42.8%) continued with weekly capecitabine or paclitaxel with no changes in treatment, and the treatment regimen was changed for 2 (28.5%) (a less myelosuppressive regimen was selected for one of them and this decision was due to the progression of the disease in the other patient). Ninety patients who were on adjuvant, neoadjuvant, or palliative HT and/or anti-HER2 therapies continued the treatment with no changes.


 > Discussion Top


Most patients diagnosed with BC in Uruguay present at an advanced age. In fact, the median age of the patients diagnosed with infiltrating BC during the period 2012–2016 was 63 years (51–74 years).[4],[5] These patients also have one or more comorbidities, which increases the risk of complications due to COVID-19.[6] Moreover, treatments with CT often cause immunosuppression; hence, cancer patients are considered to be more susceptible to developing severe SARS-CoV-2 virus infections and COVID-19.[7] Thus, cancer patients are one of the high-risk groups in the current pandemic.

A recently published meta-analysis demonstrated that 2% of COVID-19 patients in China had cancer.[8] While the available information is scarce, it shows that cancer patients with active disease are at a greater risk of developing serious complications due to COVID-19 compared to other patients; in particular, patients receiving myelosuppressive therapies.[7],[8]

However, these results should be interpreted with caution since they are based on retrospective studies with a small number of cancer patients, and with different types of cancer and various treatments.

In contrast, the incidence and mortality rates reported in Uruguay are lower than those reported internationally.

Since the declaration of the health emergency on March 13, the number of confirmed positive cases of COVID-19 registered in Uruguay is 1876. Of these, 1582 have already recovered and 248 are active cases.[9] Hence, it is doubtful whether the results reported internationally can be extrapolated to our country. Consequently, it was of special interest to understand the impact of the COVID pandemic on patients managed at the UDAM in our service.

To the best of our knowledge, this study is the first in Uruguay and in Latin America to assess the care of patients diagnosed with BC in the context of the pandemic.

In our opinion, this study is important to know and assess the health care activities provided by the UDAM during the period regarded as the “peak” of the pandemic, which could reveal differences from what has been reported internationally, due to the different progression of the pandemic in our country.

As we mentioned there were 293 medical appointments from March 13 to June 30, 2020, which indicates a decrease of 16.7% compared to the same period in 2019 at the UDAM, when there were 352 medical appointments.

Although there was a decrease in the number of medical appointments, health care service could continue as a result of the reorganization of health care activities. The telephonic triage prior to admission allowed 75% of the medical appointments to be attended in person (221). The rest (72) was through telephonic consultation.

A total of 131 patients with a median age of 60 years (ranging from 29 to 101 years) were attended to, which is consistent with what has been reported both nationally[5] and internationally.[10]

Regarding the new appointments in 2020 compared to 2019 there was a decrease of 40% in the number of patients referred to the UDAM (12 in 2020 vs. 20 in 2019). As for the number of treatments provided at the day hospital, there were 127 sessions of treatments with chemotherapy and/or anti-HER2, which represents a decrease of 10% in 2020 (115 sessions of treatments) compared to 2019. Most patients (109; 83.2%) were on systemic onco-specific treatment and only 22 (16.8%) were attended to for control of the disease. Of the patients under treatment, 81 (74%) were on HT, 21 (19%) on chemotherapy (CT), and 9 (8%) on anti-HER2 therapies. The decision to postpone or interrupt treatment in patients without confirmed COVID-19 infection considered the health situation and the risks associated with transfers and attendance at the health center, immunosuppressive effects of the treatment, objectives of the treatment (adjuvant and palliative), patient's age and comorbidities, potential benefits and risks, and whether there were therapeutic alternatives and how these compared in terms of benefit and risk with the proposed treatment.

For patients receiving CT, tests to rule out COVID-19 were conducted and extreme measures were taken to prevent respiratory infections, including the use of growth factors with or without prophylactic antibiotics, in a manner similar to that followed when high-risk chemotherapy regimens are indicated. A total of 66.6% (14) of these patients were on adjuvant/neoadjuvant CT. Of these, 9 (64.3%) continued with the same regimen with the addition of prophylactic granulocytic colony-stimulating factors (G-CSF), and 5 (35.7%) who were receiving weekly paclitaxel, continued the treatment with no changes.

A total of twenty patients initiated an oncology treatment, 14 with HT and six with CT. For initiation of CT, the conduct to be followed during the treatment was discussed, and the decision considered the recommended treatment and the patient's preference. The patients were informed of the potential benefits of the treatment, as well as the risks in the current health care situation.

For patients under palliative treatment (7; 33.3%), the response and tolerance to the treatment were assessed, and the preference of the patient, who had previously been informed of the potential benefits of the treatment and its risks in the current health situation was considered. A total of 28.5% (two patients) continued with the treatment with the addition of G-CSF, 42.8%[3] continued with weekly capecitabine or paclitaxel without changes to treatment and 28.5%[2] changed their regimen (a less myelosuppressive regimen was selected for one of them and this decision was due to the progression of the disease in the other patient).

It was decided to continue treatment with HT and targeted therapies according to the recommendations, which allowed the ninty patients who were on adjuvant, neoadjuvant, or palliative HT and/or anti-HER2 therapies to continue the treatment with no changes.

Our results reveal a decrease in the health care activities, the number of onco-specific treatments for patients with BC, and in the number of patients referred to the UDAM, as a consequence of the COVID-19 pandemic.

However, the development of guidelines for the diagnosis and oncological treatment of the patients with BC attended to at the UDAM during the COVID-19 pandemic ensured adequate oncological care.

One of the strengths of this study was the use of an anonymous and reliable database, such as the HCEO, although the data were collected retrospectively.

However, the interpretation of the results of this study should consider that this assessment was performed out only in patients managed at the UDAM of the Department of Clinical Oncology of the Clinical Hospital, which can lead to a bias in the results and therefore limits the possibility of extrapolating them to patients assisted at other centers. Therefore, further studies are required to assess health care activities, including care of patients managed at private institutions and in the country's interior areas.

We consider that the results about the care provided to our patients and the treatment modifications can help in optimizing health care activities if a similar situation was to arise again.


 > Conclusions Top


This is the first study in Uruguay to assess the care of patients diagnosed with BC. Although these are preliminary results, the available evidence suggests that despite a decrease of approximately 17% in the number of medical appointments, UDAM was able to maintain the healthcare activities and continue most treatments. The most modified treatment was CT, with the addition of prophylactic G-CSF to avoid myelosuppression and the potential complications from COVID-19 infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Ministry of Public Health. Statitics Division. Mortality Statitics. Available from: http://www.msp.gub.uy/estvitales/. [Last accessed on 2019 Apr 19].  Back to cited text no. 1
    
2.
Uruguayan Honorary Commission to fight Cancer. National Registry of Cancer. Epidemiological Situation of Cancer in Uruguay. Montevideo; May, 2020. Available from: https://www.comisioncancer.org.uy/Ocultas/SituacionEpidemiologica-del-Uruguay-en-relacion-al-Cancer--Mayo-2019- uc108. [Last accessed on 2020 Apr 02].  Back to cited text no. 2
    
3.
Recommendations about the Diagnosis and Oncological Treatment of Breast Cancer in Uruguay during the COVID-19 Pandemic. Coordination: Natalia Camejo, Cecilia Castillo, Lucía Delgado. Servicio de Oncología Clínica. Clinics Hospital. School of Medicine. Univeristy of Republic. Available from:http://www.oncologiamedica.hc.edu.uy/images/2.recomendaciones_para_el_manejo_del_Cancer_de_Mama_durante_la_Pandemia_COV ID-19_v1.0.pdf. [Last accessed on 2020 Jun 02].  Back to cited text no. 3
    
4.
Uruguayan Honorary Commission to fight Cancer. National Registry of Cancer. Ann Rep Period 2012 2016. Available from: https://www.comisioncancer.org.uy/ocultas/ cancer de MAMAMujeres uc77. [Last accessed on 2020 Apr 20].  Back to cited text no. 4
    
5.
Barrios E, Garau M. Cancer: Magnitude of the problem in the world and in Uruguay, epidemiological aspects. An Fac Med (Univ Repúb Urug) 2017;4:9-46.  Back to cited text no. 5
    
6.
Schrag D, Hershman DL, Basch E. Oncology Practice During the COVID-19 Pandemic. JAMA. 2020;323:2005-2006. doi: 10.1001/jama.2020.6236.  Back to cited text no. 6
    
7.
Liang W, Guan W, Chen R, Weng W, Li J, Xu K, et al. Cancer patients in SARS-CoV-2 infection: A nationwide analysis in China. Lancet Oncol 2020;21:335-7.  Back to cited text no. 7
    
8.
Yu J, Ouyang W, Chua MLK, Xie C. SARS-CoV-2 Transmission in Patients With Cancer at a Tertiary Care Hospital in Wuhan, China. JAMA Oncol 2020;6:1108-10. doi: 10.1001/jamaoncol.2020.0980  Back to cited text no. 8
    
9.
Ministry of Public Health. Situation Information on Coronavirus COVID-19 in Uruguay. Available from: https://www.gub.uy/ministerio-saludpublica/comunicacion/noticias/informacion-situacion-sobrecoronavirus-covid-19-uruguay-11. [Last accessed on 2020 Apr 02].  Back to cited text no. 9
    
10.
Surveillance, Epidemiology, and End Results (SEER): Median age of Cancer Patients at Diagnosis, 2007 2011, by Primary Cancer Site, race, and sex. Available from:https://seer.cancer.gov/archive/ csr/1975_2011/results_single/sect_01table. 12_2pgs.pdf. [Last accessed on 2020 Apr 20].  Back to cited text no. 10
    




 

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