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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Pattern of Practices of Oncologists of Bangladesh in the COVID-19 Era


1 Department of Radiation Oncology, Evercare Hospital, Dhaka, Bangladesh
2 Department of Clinical Oncology, Lab Aid Cancer and Specialized Hospital, Dhaka, Bangladesh
3 Department of Oncology, Bangladesh Specialized Hospital, Dhaka, Bangladesh
4 Department of Medical Oncology, European Institute of Oncology, IRCCS, Milan, Italy

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Date of Submission22-Sep-2021
Date of Acceptance08-Dec-2021
Date of Web Publication14-Apr-2022
 

  Abstract 

Purpose: The aim of this study was to investigate the impact of coronavirus disease-2019 (COVID-19) on the practice of oncology care in Bangladesh during the first pandemic surge in 2020. Materials and Methods: This was a cross-sectional survey-type study, based on a questionnaire, which was shared via email to national oncologists and enhanced by snowballing in April–May 2020. Results: A total of 48 responders joined the survey, mostly clinical and radiation oncologists practicing in specialized cancer centers of the major cities. Patients’ triage for COVID-19 was implemented in 60% of the settings surveyed, and an impact on the clinical care was unanimously reported. Delays and interruptions in cancer treatments were common, as was a reduction of patient volume treated with radiation therapy (RT). Mechanisms for priority-setting to inform clinical decisions were set by 80% of the oncologists, including changes in the treatment protocols––more commonly for palliative care interventions and regarding the RT fractionation; also, alternative therapeutic options were more commonly discussed, particularly when patients were candidate to multimodal treatments. Value-driven and choose-wisely approaches were emphasized. Telemedicine was identified as a mechanism to reduce access to hospitals, but only for selected services (e.g., follow-up) by 78%. Protecting hospitals and health workers were identified as priority interventions to shape effective COVID-19 responses. Conclusion: This survey serves as a case study of adaptations of cancer care during COVID-19 in low- and middle-income countries. Elements of priority-settings and value-driven decision-making emerged, although the long-term impact cannot be stated, at this time.

Keywords: Bangladesh, cancer, COVID-19, national survey, non-communicable diseases, service disruption


How to cite this URL:
Chowdhury AR, Banu PA, Rahman MA, Trapani D. Pattern of Practices of Oncologists of Bangladesh in the COVID-19 Era. Bengal J Cancer [Epub ahead of print] [cited 2022 Nov 30]. Available from: http://www.bengaljcancer.org/preprintarticle.asp?id=343221





  Introduction Top


The coronavirus disease-2019 (COVID-19) pandemic started officially in Bangladesh on March 8, 2020, when the first three cases were officially diagnosed. As of April 2021, more than 147 million cases have been reported across 220 countries and territories, with more than 3 million deaths.[1] In Bangladesh, 745,000 and 11,000 cases and deaths have been reported since March 2020, cumulatively. The COVID-19 outbreak significantly impacted the worldwide health-care systems, challenging entire societies and economies across the globe. The need to prioritize essential health services to face the pandemic has resulted in various health system disruptions in countries, which has been particularly challenging and impactful in low- and middle-income countries. According to the World Health Organization (WHO), disruptions in cancer care services have been reported in nearly half of the countries in the world, affecting the entire cancer continuum.[2] Oncology facilities have faced different types of challenges to provide cancer care. Cancer patients have been identified as a category of vulnerable persons, as experiencing the more severe outcome from COVID-19.[3] However, the impact on cancer patients has also been reported indirectly, as a result of the health system disruptions and impaired access to cancer care. One study from the UK, for example, estimated 60,000 additional avoidable years of life lost resulting from diagnostic delays due to the COVID-19 pandemic.[4] In poorly functioning health systems, the major threat is the development of adjunctive capacity to restore health services for cancer care, whereas resources are depauperated with the pandemic surge.[5] In low- and middle-income countries like Bangladesh, challenges affect the availability of health resources and pave a difficult way to reallocate funding for oncology capacity building and scale-up.

In the aim to better understand the impact of COVID-19 on low- and middle-income countries, we conducted an online survey among oncology professionals of Bangladesh, as a case study of oncology practice patterns during pandemics.


  Materials and Methods Top


A 20-question online survey was developed by the authors to investigate the patterns of clinical practice in Bangladesh during the COVID-19 pandemics. The survey included multiple choices and open-answer options. The questionnaire was exempted by Institutional Review Board (IRB) approval, qualified as a low-risk health investigation on evaluation of performance or effectiveness of public benefit or service programs, during exceptional health conditions. Study participation was voluntary; subjects were enrolled after a complete presentation of the research in a cover letter, and possible conflicts of interest and financial support were outlined. Data processing complied with the EU General Data Protection Regulation (GDPR 2016/679) for information security. The survey was shared by email from a national network of registered cancer providers. The survey was active between 15 April and 31 May 2020. Data were analyzed using descriptive statistics (Excel software, Microsoft Corporation, Redmond, Washington).


  Results Top


Seventy-eight oncologists were identified nationwide, and 48 responded to contribute to this study (response rate: 61.5%). The majority of the professionals were radiation oncologists comprising 56.25% (n = 27) of total respondents. The rest of the responders (43.75%) were clinical oncologists. Responders were almost all specialist professionals (n = 42), whereas only a few were resident physicians or enrolled in other training programs (n = 6). Most of the respondents were practicing in Dhaka, the capital city of Bangladesh, and were working in specialized cancer centers (54.16%, n = 26) [Figure 1]. Three-quarters (n = 35) of the oncology professionals reported that during the survey time, the COVID situation was in rapid surge, in the peak phase, but 18.75% (n = 9) perceived to be in the early phase of it.
Figure 1: Distribution of the survey responders in Bangladesh. This image is original and developed specifically for this study

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Oncology professionals were asked different questions about the practicing patterns. Sixty percent of the health providers had implemented a triaging system before admitting patients in their institutions, whereas the remaining physicians reported no mechanism in place for triage [Figure 2]. Almost all the responders (n = 47) had changed their pattern of clinical practice, resulting from health service disruptions amid pandemics. Around a quarter of responders (n = 13) reported to have unchanged outpatient consultations (OPD) for cancer care; however, the majority of responders (n = 35) were doing OPD consultation on a roster basis. For patient care, 78% of oncology professionals agreed for remote consultation by telemedicine, however only endorsed for follow-up OPD.
Figure 2: Implementation of a triage mechanism to screen patients for COVID-19 in oncology departments and facilities

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Delays in established patients in clinical follow-up were common (n = 39), as a result of the reorganization of the health services. A lower number of daily new patients starting radiation therapy were also commonly described (n = 39): only seven responders did not find changes in the patient’s volume [Figure 3]. In addition, for 25% of the oncologists, the health system reorganization had resulted in delays and treatment discontinuations. Eighty percent of the providers (n = 38) applied some mechanism of priority-setting to organize the schedules of oncology treatments and decide for delays and withdrawal based on the magnitude of benefit. Changes in therapeutic protocols were reported (n = 31): the use of hypofractionated radiotherapy instead of conventional schedules was the most common treatment variation preferred by the oncologists, along with less complex techniques of radiotherapy. Treatment variations concerned mainly breast cancer care and palliative care.
Figure 3: Impact of the COVID-19 pandemic on the health services for patients with indication to radiation therapy

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Approximately 84% of oncologists commented that they were not advising any invasive investigation during follow-up visits of the patients, unless strictly mandatory (e.g., medical urgency, essential diagnostics for treatment decisions). Approximately 60% of the oncologists were in favor of giving concurrent chemotherapy along with radiation, as before. But the rest were in favor of an individualized decision, including the provision of an alternative treatment approach (e.g., only chemotherapy or only radiotherapy), based on the ultimate therapeutic value of the multimodal treatments. There was agreement (72%) to avoid starting cancer treatments in patients with COVID-19.

Regarding the availability of personal protection devices in hospitals during COVID-19, 90% of the oncologists had access to appropriate personal protection equipment (PPE), as mandated by the international protocol for health providers.


  Discussion Top


This survey provides a snapshot as of May 2020 of the practice pattern of oncologists in Bangladesh during COVID-19. We found that during the coronavirus pandemic, most of the oncology services in Bangladesh were experiencing various disruptions amidst pandemics. However, a complete shutdown was not reported. To the best of our knowledge, this is the first report in the literature of the health system disruptions in Bangladesh, related to COVID-19. Ensuring the safety of the health facilities emerged as a nationwide priority from the survey, both for personal protection with PPE and patient triaging, to reduce the risk of COVID-19 spread in the hospitals. Protecting healthcare institutions has been, therefore, a critical component of the overall response to the pandemic. Variations in the clinical protocols to meet the health demands from COVID-19 surge were largely reported, essentially as priority-based mechanisms driven by value-based decision-making. Also, decisions to withdraw and postpone services were common, mainly in the follow-up setting, and telemedicine was identified as an elective approach for selected outpatient services.

Limits of these surveys are related to the development process and sharing system. The survey was based on a scoping research of the literature and by consulting the WHO technical reports for the evaluation and monitoring of health system changes during pandemics. However, there were neither nationwide agreements nor multistakeholder consultation. Also, the oncologists were reached through snowballing, so we could not assure the maximal coverage of health providers. However, the response rate is quite high: it is estimated that in the country, approximately 200 oncologists are practicing––and we were able to cover approximately one-fourth of the national cancer workforce, based on the last available estimates.[6] In addition, to the best of our knowledge this is the first nationally focused research of this type and with this descriptive granularity.

Although not formally surveyed, it is quite clear that decision-making mechanisms have been implemented in Bangladesh based on the recommendations of the international cancer societies.[7] How urgent were these dispositions to be implemented is unclear. But it is clearer that in May 2020, there was a perception of a severe national situation, when Bangladesh was in the rising phase of the pandemic curve, which peaked later in June–July 2020.[8] However, the rapid health system pressure at that time was perceived by the health providers as plateauing, perhaps for the impact on the health system occurring at that time, and the perception of tangible changes related to the abrogation of some services, ultimately reducing the access of patients to health institutions. The findings could mirror the perception of the pandemic phases as communicated by institutions and governmental technical bodies, and the media press activities.[9]

The opportunity to prioritize the most valuable health interventions and disengage from low-value therapies has been accelerated by the uptake of choose-wisely frameworks, during COVID-19, in several countries.[3],[10] However, not all the decisions have been immediately received, and a multitude of countries have decided to shut down almost all their key services temporarily, commonly in concurrence with decisions to lockdown. In the aim to protect the vulnerable patients with cancer and other conditions of immune-suppression, and respond to the surge of pandemic, many health services were abrogated, in all the countries. However, although the decisions to abrigate “Non-essential” services was initially embraced as critical, longer time consequences might be anticipated, including detrimental delays in diagnosis.[11] Moreover, disruptions occurring in weaker health systems and less resilient contexts are not surely expected to be promptly rescued at a certain point, and in the short term: abrogating cancer services in low- and middle-income countries is risky and can generate permanent barriers for patients, for the inaccessibility to specialized healthcare. The treatment patterns of clinical cancer care amidst pandemics from our survey are consistent with the body of the research on the topic. For instance, one prospective multicenter UK data collection of patients with stage I to III lung cancer reported 37% of the patients experienced changes in the treatments received: different radiotherapy dose or fractionation and decision to opt for radiotherapy instead of surgery were the most common changes.[12] These findings are consistent with our survey. A systematic review of the literature well documented the delays or disruptions affecting the routine activity of cancer services and some cancer surgeries, delays in radiotherapy, and cancellation of outpatient visits––variably due to interruptions and disruptions of facilities, supply chains, and availability of health workforce.[13] Preserving cancer prevention and control services is therefore a priority in the aim to tackle major service abrogation and uncritical changes. Mitigating the effects of health system disruptions is also challenging, and the evidence of a positive impact of organization’s strategies is quite narrow, at the moment.[13]

The implications of adaptations in cancer services and clinical practice during COVID-19 must be accurately accounted. Apparently, acceptable decisions can result in long-term adverse consequences that reverberate through the pandemic wave, and result in detrimental population health effects. The survey from Bangladesh suggests a value-based approach for the clinical decision-making to assure the prioritization of treatments with greatest benefits with the resource available. Although the long-term impact cannot be now predicted, data accountability must be assured, to track impact of decisions, and provide prompt actions in response. Preserving and strengthening the health system resilience in Bangladesh with structural priority investments and value-driven service delivery is the key to secure sustainable and impactful future for the national oncology care and work to build back better.

Acknowledgement

The authors thank sincerely all the survey responders and express greatest gratitude in helping complete this nationwide project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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World Health Organization (WHO). Coronavirus disease (COVID-19) weekly epidemiological update and weekly operational update. 2021. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports [Last accessed on 2021 Apr 26].  Back to cited text no. 1
    
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World Health Organization. Rapid assessment of service delivery for NCDs during the COVID-19 pandemic; 2020. Available from: https://www.who.int/publications/m/item/rapid-assessment-of-service-delivery-for-ncds-during-the-COVID-19-pandemic. [Last accessed on 2021 Apr 26].  Back to cited text no. 2
    
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Maringe C, Spicer J, Morris M, Purushotham A, Nolte E, Sullivan R, et al. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: A national, population-based, modelling study. Lancet Oncol 2020;21:1023-34.  Back to cited text no. 3
    
4.
Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. Cancer patients in SARS-CoV-2 infection: A nationwide analysis in China. Lancet Oncol 2020;21:335-37.  Back to cited text no. 4
    
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[PUBMED]  [Full text]  
6.
European Society for Medical Oncology (ESMO). Cancer patient management during the COVID-19 pandemic. 2021. Available from: https://www.esmo.org/guidelines/cancer-patient-management-during-the-COVID-19-pandemic. [Last accessed on 2021 May 11].  Back to cited text no. 6
    
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Correspondence Address:
Arman Reza Chowdhury,
Dr. Arman Reza Chowdhury, Department of Radiation Oncology, Evercare Hospital, Dhaka
Bangladesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjoc.BJOC_22_21



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