In scramble over COVID, the patients we forgot
Treatment delay part of fallout of pandemic prep
Jim Mann recites the numbers without hesitation: he had 19 tests and seven meetings during a marathon week of screening at a Toronto hospital in March.
The reward at the end was nothing less than a new chance at life, a spot on the facility’s lung transplantation list as emphysema cuts his own lungs’ capacity by almost 75 per cent.
Then just days later, the University Health Network called to inform him everything was on hold.
Mann knew he still had to wait for a matching organ from a deceased donor. But Ontario’s cancellation of “elective” surgeries to ready for a feared surge of COVID-19 patients meant nothing could be done for him until the restrictions were lifted.
“It’s very heartbreaking, to be honest,” says Mann, a retired home-renovation salesman from Niagara Falls.
“It’s definitely worrisome. I’m only 65 years old.”
He’s part of the overlooked fallout from the pandemic lockdown — the thousands of Canadians whose treatments have been delayed for close to two months already and could be postponed for weeks more.
Almost 200,000 surgeries and other procedures, cancer screening tests and clinical trials of experimental medicines were shelved indefinitely as hospitals braced for a possible flood of COVID-19 patients, a deluge that never quite materialized.
Meanwhile, many hospitals have sat barely half-full.
Doctors and patient advocates say the dramatic, overnight retooling of the nation’s health-care system, luckily, didn’t trigger a tsunami of deaths or other bad outcomes for non-COVID patients, thanks largely to careful planning.
But there is evidence of negative impacts nonetheless.
Modelling in Ontario estimated the cancellation of elective heart surgeries would result in more than 30 deaths by early May.
Colleagues of Dr. Andrew Krahn, Vancouver-based president of the Canadian Cardiovascular Society, called to check on a patient awaiting the pandemic-delayed implant of a defibrillator, a device designed to prevent lethal heart rhythm problems. His daughter answered, revealing that the patient had already died, says Krahn.
Delia Oliveira, a Surrey, B.C., woman, told media that her 50-year-old husband, Chris Walcroft, passed away April 15, weeks after the procedure to prepare him for life-saving kidney dialysis was cancelled.
For other patients, there’s the anxiety of having to wait longer to have a tumour removed, clogged artery cleared or painful joint replaced. In Ontario, only about 20 to 40 per cent of the usual volume of elective cancer surgeries has taken place during the lockdown, estimates Dr. Chris Booth, an oncologist and professor at Queen’s University.
“That’s been a massive problem for patients,” he said. “You can imagine how anxiety-provoking a cancer diagnosis is at the best of times, let alone during COVID-19 … and then on top of that they have uncertainty about when they can have their surgery.”
Provinces like Ontario and B.C. announced this week they’re resuming the suspended operations, but now have to cope with the backlog. That could take as much as two years to clear in British Columbia, Health Minister Adrian Dix said this week.
And the longer the delays last, the worse the possible outcomes, predicted the Ontario Financial Accountability Office in a report on the pandemic, echoing others’ concerns.
“Sad comment: It will become more and more difficult to reassure our patients about the impact of this delay on their prognosis,” wrote Dr. Diane Francoeur, president of the Quebec Federation of Medical Specialists, in a newsletter Monday.
“This is the great stress,” said Eva Villalba of the Quebec Cancer Coalition. “If you have a stage-three cancer or stage two that is still operable, you can wait four to six weeks. But if you finally get operated on four months later, maybe it’s not operable any more, maybe it’s progressed to a stage-four cancer.”
Hospitals began to transform themselves in the middle of March as horror stories from Italy convinced authorities they had to free up room on wards and in intensive care units for potential COVID-19 sufferers. Cancelling non-emergency and non-urgent operations, the thinking went, would mean fewer patients recovering in ICUs — or being exposed to the infection.
Since the changes began, Ontario has performed 72,400 fewer surgeries than the year before, while B.C. saw 30,000 cancelled. A rough extrapolation based on their share of the population points to 189,000 postponed operations nationwide.
But with stay-at-home orders and other factors flattening the epidemic curve, the COVID-19 wave never reached near the heights it did in places like New York City.
By mid-April, Ontario hospitals that are typically at close to 100 per cent capacity were just 69 per cent full, with 11,200 free beds, according to the Financial Accountability Office.
Quebec’s Villalba, like other patient advocates, doesn’t question the decision to largely clear hospitals of non-COVID patients, but believes too little heed was paid the patients affected by the momentous shift. Many found out about their cancellations by automated message.
“At the beginning, we do feel that other patients were completely forgotten and abandoned,” she said. “They don’t want to be sacrificed in the name of COVID patients.”
Health authorities insist non-coronavirus patients never were abandoned, and that triaging meant those who needed surgery urgently got it within a reasonable time.
In Ontario at least, only cancer patients with slow-progressing tumours were affected, argues Dr. Ralph Meyer, a vice-president of oncology at Hamilton Health Sciences and a regional head of Cancer Care Ontario.
And for patients with breast cancers at an earlier stage, for instance, there is good evidence that a twomonth surgery delay is not going to affect their overall survival, said Dr. Jory Simpson, a surgical oncology professor at the University of Toronto.
But that has done little to relieve patients’ fears, especially when the risk around delay was not well-explained to many of them, said Villalba. Surveys by her coalition and Rethink Breast Cancer, a national advocacy group for young patients, both found about 70 per cent of patients whose procedures were cancelled felt high anxiety.
“That is very emotionally unsettling for most cancer patients,” said MJ DeCoteau,
Rethink’s founder.
“The instinct is ‘I have cancer, I want it out of my body.’ ”
Deb Maskens, a kidney cancer patient and spokeswoman for the cancer advocacy group CanCertainty, said she’s spoken to many patients who are “freaking out” because of surgery delays. But she urges them to have faith in their doctors, saying there’s actually no burning urgency to remove a malignancy that is not growing aggressively.
MRIs, CT scans and other diagnostic tests for cancer have also been pared back where deemed safe to do so, reducing the number of scans by 25 per cent in Ontario, that province says.
Regular screening tests — mammograms, pap smears, colon-cancer tests — have been put on hold. Screening is by definition for asymptomatic people and designed to find cancers early, but it’s unclear what the impact will be, said Meyer.
Chemotherapy and radiation treatment have gone ahead in many provinces, though with “pauses” for some patients, said Maskens. There’s little evidence as to what effect that change will have, either, she said.
Meanwhile, some patients waiting for surgery or other treatment are being prescribed oral, take-home drugs, such as tamoxifen, that can fight the cancer but typically would be started later in treatment.
New trials of experimental drugs, often the last best hope for patients with metastatic cancers, though, have also been halted, noted Villalba.
For heart patients, cardiac specialists are trying to keep in regular contact so if symptoms like fainting suddenly appear, their delayed surgery can be moved ahead, said Krahn.
Meanwhile, physicians are concerned about another side effect of the pandemic: a reluctance on the part of some Canadians to seek help when they feel ill.
“The people who do come to hospital are sicker,” said cardiologist Krahn. “That’s because they started getting sick and they waited until they were desperate to come in.”
Indeed, the family member of a cardiovascular society employee in Ottawa started feeling acutely unwell recently, put off seeking help and three days later died in her sleep. She had likely suffered a heart attack, then heart failure, said Krahn.
Ontario has reported a 30-per-cent reduction and B.C. a 40-per-cent drop in people presenting to emergency departments with STEMIs, the most serious type of heart attack, according to the Heart and Stroke Foundation of Canada.
There also seems to be less demand for MRIs, CT scans and other diagnostic tests that can detect cancer, again suggesting people are avoiding help, said Meyer.
“What are we missing?” he asked. “Are people tolerating things because of the hope they’re just going to blow over?”
Mann certainly is not avoiding treatment for his condition, which forced him to quit his job and start using an oxygen tank eight years ago.
But if the hospital eases its lockdown and allows visitors like his wife Lori by the time he has his doublelung transplant — an operation that can last 12 hours — that would be a definite silver lining.
“This is pretty major stuff I’m going to go through,” he said. “I don’t want to do it alone.”
THEY DON’T WANT TO BE SACRIFICED IN THE NAME
OF COVID PATIENTS.
National Post