© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
Impact of the COVID-19 pandemic on cancer care
Junjie Huang, PhD, MSc1,2,3; Harry HX Wang, PhD1; ZJ Zheng, MD, PhD4,5; Martin CS Wong, MD, MPH2,3,5,6
1 Editor, Hong Kong Medical Journal
2 The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
3 Centre for Health Education and Health Promotion, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
4 International Editorial Advisory Board, Hong Kong Medical Journal
5 Department of Global Health, School of Public Health, Peking University, Beijing, China
6 Editor-in-Chief, Hong Kong Medical Journal
Corresponding author: Prof Martin CS Wong (firstname.lastname@example.org)
Status of COVID-19 worldwide and in Hong Kong
As of November 2022, there have been >600 million confirmed cases of coronavirus disease 2019 (COVID-19) worldwide, including 6 million deaths, since the pandemic began in 2020.1 In Hong Kong, the number of cases has reached >2 million, with >10 000 deaths. Since the initiation of the vaccination programme in 2021, >94% and >83% of the population have received the first and third doses, respectively.2 In addition to its impacts on infected individuals, the COVID-19 pandemic has affected the general public and physicians.3 4 5
Relationship between the COVID-19 pandemic and cancer
Patients with cancer are more aware of the impact of COVID-19 because of their increased risk of infection. This risk of infection arises from factors such as the presence of an immunocompromised status related to disease or treatment, the nature of cancer as a major co-morbidity that enhances the risks of COVID-19–related morbidity and mortality, and the need for frequent visits to medical centres to receive anticancer treatment and cancer-related care.6 7 A study conducted in China showed that patients with both COVID-19 and cancer had 3.5-fold greater odds of requiring mechanical ventilation, intensive care unit admission, or death, compared with healthy individuals.8 Patients with cancer also had a higher risk of COVID-19 infection and experienced worse outcomes, compared with patients who did not have cancer.9 10 Additionally, one study showed that the onset of COVID-19 could lead to higher mortality (24%) among patients with cancer than among patients without cancer (3%).10 11
Impact of COVID-19 on cancer screening
The COVID-19 pandemic has led to reductions in cancer screening services in relation to the suspension of non-urgent medical services, rescheduling to focus on COVID-19–related services, and reduced patient motivation to seek care.12 13 14 Affected services include colorectal, cervical, lung, and prostate cancer screenings.
For example, colorectal cancer screening capacity in the United States has decreased by 86%, and up to 1500 colorectal cancer cases have been missed or delayed in Australia during the COVID-19 pandemic thus far.12 The effectiveness of colorectal cancer screening services is compromised because there is an increased risk of COVID-19 transmission associated with endoscopy and the exposure of vulnerable people to the hospital environment. These impacts have been reported in multiple countries worldwide, including the United States, United Kingdom, Ireland, Australia, and Italy.12 Additionally, one study showed that a large proportion of women in Hong Kong have never undergone cervical cancer screening; this lack of screening has been exacerbated during the COVID-19 pandemic because of restricted access to medical centres.13 Social distancing and concerns about potential exposure have deterred women from seeking clinical care, thereby reducing in-person screening.10 Another study revealed the potential for missed cancer diagnoses (prostate, 19.7%; colorectal, 10%; and lung, 3%) because of the COVID-19 pandemic in Hong Kong.14
Impact of COVID-19 on cancer treatment and patient life
The COVID-19 pandemic has had diverse effects on patients with cancer; the greatest impacts have involved effects on patients’ lives and access to cancer treatment modalities. Researchers in Hong Kong recently published the results of a multidisciplinary cross-sectional survey that examined the real-world impact of the pandemic on patients with cancer in May 2020.15 The survey found that patients accepted increased physical distance from medical staff during consultations; patients were able to refill their medications without oncologist consultations. Although some patients receiving chemotherapy or radiotherapy chose not to modify their treatment plans, many patients were willing to balance a change in treatment efficacy or side-effect profile with the ability to undergo out-patient treatment. Among patients with cancer, social distancing measures during the pandemic have changed attitudes and experiences related to medical consultation and cancer treatment; these changes have tended to continue as the pandemic severity has declined.15 16 17
Implications for cancer care during the pandemic
Research has shown that although cancer services continue to function with adaptive measures and patient acceptance, many patients are hesitant to visit hospitals. This hesitance is related to inadequate information regarding COVID-19 among patients with cancer, particularly with respect to hospital safety measures focused on COVID-19.16 Therefore, patients with cancer should receive timely information about COVID-19 from official sources, through various channels (eg, the internet and social media), regardless of their age and socio-economic status.
Research findings have also emphasised the real-world needs of patients with cancer in terms of individualised dietetic and occupational health assessments, early in-patient or out-patient interventions, and self-help materials for cancer care developed in the context of the pandemic. Such considerations should include telemedicine, which has become popular during the pandemic; because it sometimes cannot be accessed and understood by underprivileged individuals (eg, older adults and less educated patients), telemedicine should not fully replace conventional physiotherapy and rehabilitation.17 The issue of telemedicine was also addressed in a study focused on new cancer diagnoses. Among patients who experienced difficulty understanding their cancer diagnosis (eg, cancer type, stage, and treatment options), the use of telemedicine may lead to increased anxiety and confusion. Thus, clinical visits are preferable for new patients.18
The decision to continue or discontinue treatment (chemotherapy or surgery) is a key consideration for patients with cancer who may have an increased risk of infection during the pandemic. The results of some studies suggest that adjuvant chemotherapy or surgery can be postponed for patients with cancer who exhibit stable disease, whereas the results of other studies suggest that those aspects of treatment should be continued to prevent COVID-19 transmission. The findings of one study indicated that adjuvant chemotherapy with curative intent should be maintained for early-stage cancer.18 Robust precautionary measures should be implemented for chemotherapy infusion areas (eg, nucleic acid testing, quarantine, and isolation) to protect immunocompromised patients.18 Nevertheless, that study did not include patients with cancer who received treatments in private clinics. Moreover, future studies should cover longer periods of time (ie, not limited to the first wave of the COVID-19 pandemic), considering that there were five waves of COVID-19 in Hong Kong before November 2022.19 In addition to clinical outcomes, patient-reported outcomes should be explored among patients with cancer.20 Additional studies are needed regarding the long-term impact of the COVID-19 pandemic on cancer care to determine how it may affect the cancer burden in Hong Kong during the post-pandemic era.
All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
Conflicts of interest
All authors have disclosed no conflicts of interest.
We thank Ms Yuet-yan Wong, Senior Research Assistant from the Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, for her assistance in the literature search and review.
1. World Health Organization (WHO). WHO coronavirus (COVID-19) dashboard. Updated 2022 Nov 27. Available from: https://covid19.who.int/. Accessed 30 Nov 2022.
2. Hong Kong SAR Government. Coronavirus disease (COVID-19) in HK. Updated 2022 Nov 27. Available from: https://chp-dashboard.geodata.gov.hk/covid-19/en.html. Accessed 30 Nov 2022.
3. Wang Y, Luo S, Zhou CS, et al. Clinical and radiological characteristics of COVID-19: a multicentre, retrospective, observational study. Hong Kong Med J 2021;27:7-17. Crossref
4. Tam VC, Tam SY, Khaw ML, Law HK, Chan CP, Lee SW. Behavioural insights and attitudes on community masking during the initial spread of COVID-19 in Hong Kong. Hong Kong Med J 2021;27:106-12. Crossref
5. Yu EY, Leung WL, Wong SY, Liu KS, Wan EY; HKCFP Executive and Research Committee. How are family doctors serving the Hong Kong community during the COVID-19 outbreak? A survey of HKCFP members. Hong Kong Med J 2020;26:176-83. Crossref
6. Kong X, Qi Y, Huang J, et al. Epidemiological and clinical characteristics of cancer patients with COVID-19: a systematic review and meta-analysis of global data. Cancer Lett 2021;508:30-46. Crossref
7. Al-Quteimat OM, Amer AM. The impact of the COVID-19 pandemic on cancer patients. Am J Clin Oncol 2020;43:452-5. Crossref
8. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol 2020;21:335-7. Crossref
9. Xia Y, Jin R, Zhao J, Li W, Shen H. Risk of COVID-19 for patients with cancer. Lancet Oncol 2020;21:e180. Crossref
10. Yeoh CB, Lee KJ, Rieth EF, et al. COVID-19 in the cancer patient. Anesth Analg 2020;131:16-23.Crossref
11. Kim YJ, Lee ES, Lee YS. High mortality from viral pneumonia in patients with cancer. Infect Dis (Lond) 2019;51:502-9. Crossref
12. Huang JJ, Zhang L, Xu WH, Wong MC. Impact of COVID-19 on colorectal cancer screening: evidence and recommendations. J Soc Physicians Hong Kong 2021;13:4-6.
13. Ngu SF, Lau LS, Li J, et al. Human papillomavirus self-sampling for primary cervical cancer screening in under-screened women in Hong Kong during the COVID-19 pandemic. Int J Environ Res Public Health 2022;19:2610. Crossref
14. Vardhanabhuti V, Ng KS. Differential impact of COVID-19 on cancer diagnostic services based on body regions: a public facility-based study in Hong Kong. Int J Radiat Oncol Biol Phys 2021;111:331-6. Crossref
15. Bao KK, Cheung KM, Chow JC, et al. 1709P Cancer patients’ perspectives on the real-world impact of COVID-19 pandemic: a multidisciplinary survey. Ann Oncol 2020;31:S1006. Crossref
16. Chan WL, Ho PP, Yuen K. Social distancing and cancer care during the COVID-19 pandemic. BMJ Support Palliat Care 2020 Sep 4. Epub ahead of print. Crossref
17. Lou E, Teoh D, Brown K, et al. Perspectives of cancer patients and their health during the COVID-19 pandemic. PLoS One 2020;15:e0241741. Crossref
18. Jindal V, Sahu KK, Gaikazian S, Siddiqui AD, Jaiyesimi I. Cancer treatment during COVID-19 pandemic. Med Oncol 2020;37:58. Crossref
19. Hong Kong SAR Government. Archive of statistics on 5th wave of COVID-19. Updated 2022 Nov 27. Available from: https://www.coronavirus.gov.hk/eng/5th-wave-statistics. html. Accessed 30 Nov 2022.
20. Ng CF, Kong KY, Li CY, et al. Patient-reported outcomes after surgery or radiotherapy for localised prostate cancer: a retrospective study. Hong Kong Med J 2020;26:95-101. Crossref