‘No good time to have cancer, but this is the worst time’
As hospitals begin surgeries postponed due to COVID-19 crisis, many patients faced heightened fears and anxiety over delays
Seven weeks after she was supposed to have cancer surgery, Margaret Sadowski finally had her operation on Tuesday.
In early March, she was told that a tumour in her colon would be removed within 28 days. But in mid-March, the surgery was cancelled.
The 60-year-old Etobicoke woman is one of more than 52,000 Ontarians whose surgeries and procedures were cancelled or delayed to free up space for potential COVID-19 patients, according to the Financial Accountability Office of Ontario.
Elective surgeries effectively came to a halt after March 15.
Cancer surgeries, considered time sensitive rather than elective, continued but at a lower rate. Many, like Sadowski’s, were cancelled and later rescheduled.
Getting a diagnosis of colorectal cancer in January was devastating, Sadowski said in a recent interview. Getting bumped from her first surgery date heightened her fear.
“What if the cancer grows? What if it spreads?” she recalls asking herself.
Sadowski had trouble sleeping, dropped 10 pounds and had to go on anti-anxiety medication.
“There is no good time to have cancer, but this is the worst time to have cancer given what is happening in hospitals,” she said.
Worldwide, the pandemic will likely lead to 28 million surgeries cancelled or postponed over 12 weeks, according to a study published last week in the British Journal of Surgery.
That includes 394,576 surgeries in Canada, 27,390 of them for cancer.
It would take 11 months to clear the Canadian backlog if the number of surgeries performed weekly is increased by 20 per cent compared to the pre-pandemic pace, the study estimates.
“This is a challenge without parallel in the history of Ontario’s health-care system.”
Anthony Dale, president, Ontario Hospital Association
“Understanding these numbers will help to prepare for post-peak pandemic in order to start a plan for reopening elective surgery in a way that is safe and manageable,” said Janet Martin, an associate professor of anesthesia and perioperative medicine at Western University’s Schulich School of Medicine and Dentistry. She is part of the CovidSurg Collaborative, an international research network that did the modelling for the study.
Ontario’s hospital sector is planning for the gradual resumption of elective surgeries, beginning this week. On Thursday, the province greenlit hospitals to gradually ramp up, so long as they meet certain conditions.
Each of the province’s five regions must reserve at least 15 per cent of acute-care capacity for COVID-19 patients, among other things.
Juggling competing demands is a big ask of Ontario’s 141 hospitals, which have been bursting at the seams for years. Ontario’s rate of total hospital beds per 1,000 people is among the lowest when compared to nations in the Organization for Economic Co-operation and Development.
Creating enough surge capacity to get through flu season has become a perennial struggle.
Creating enough capacity to get through a pandemic — with a large and growing surgery backlog — will challenge hospitals like never before.
“Our collective challenge will be protecting surge capacity and managing growing occupancy levels while at the same time providing access to elective activity,” explained Anthony Dale, president of the Ontario Hospital Association. “This is a challenge without parallel in the history of Ontario’s health-care system.”
Sadowski learned she had a tumour in January following a colonoscopy. A pathology report suggested it was stage 1 or 2. She wouldn’t know for sure until after surgery.
“It’s so stressful,” she said, likening the diagnosis to being on the “Drop Zone” ride at an amusement park. “The floor falls out from under you.”
The one thing she knew about colorectal cancer was that early diagnosis and treatment are key to a good prognosis.
What made the cancellation of her first surgery date especially difficult was knowing there were unused operating rooms and unused beds in hospitals. They were left vacant so that hospitals could prepare for an expected crush of COVID-19 patients.
“I don’t feel cancer patients should take a backseat to COVID. Why are they prioritizing COVID patients first?” Sadowski asked. “Why can’t they start cancelling surgeries once they actually get COVID patients?
In the meantime people can get their cancer surgeries.”
Dale said he empathizes with patients and hopes they appreciate hospitals are trying to do their best during an unprecedented time.
“This is a heart-wrenching situation,” he said. “In this extremely difficult challenge all we can do is ask for people’s understanding in the knowledge that hospitals are doing all they can.”
Ontario hospitals were, on average, at 96-per-cent capacity before the pandemic. Some 28 hospitals had average occupancy rates of more than100 per cent.
In mid-March, after the World Health Organization declared a pandemic, there was concern that hospitals would become overwhelmed like those in New York City and parts of Europe.
By April 13, hospital capacity had fallen to 69 per cent and 11,200 hospital beds were unoccupied, according the Financial Accountability Office of Ontario.
By May 10, hospital capacity had increased to 77 per cent.
Sadowski’s surgeon, Dr. Shady Ashamalla, head of the general surgery division at Sunnybrook Health Sciences Centre, said he has never seen so many empty beds. “We didn’t know how much capacity we would need and we were afraid we would need a lot, so we scaled way back,” he explained.
“Never in its history has Sunnybrook been as low. It’s never been at 65 to 70 per cent capacity. We created that capacity so we would have a safe buffer,” he continued.
Ashamalla helped free up beds by phoning about 50 patients at the end of March to inform them that their surgeries were being postponed. Sadowski was among them.
They were difficult conversations, the surgical oncologist recounted.
“I had patients negotiating and begging for any way to get their surgeries done. It’s extremely hard to hear patients you care about in a therapeutic relationship be that scared and terrified,” he said.
Ashamalla said he likes to help patients by bringing order to the chaos of a cancer diagnosis through the creation of a surgical plan.
“It was so unnatural to add to the chaos instead of taking it away,” he said.
Sunnybrook usually has 25 operating rooms running, but that number fell to 10 in mid-March. Priority was given to cancer patients whose prognosis was likely to worsen if they did not have surgery within four weeks.
In late March, the number of ORs fell again, this time to four. The triaging system was altered to give priority to patients whose prognosis was likely to change if they did not have surgery within two weeks.
The province’s hospitals were not overrun to the extent feared.
“The people of Ontario have done an incredible job of flattening the curve to save our health-care system and now it is the responsibility of that system, which belongs to all of us, to save the people from all of the diseases that have not slowed down during this pandemic,” Ashamalla said.
Advising the province on how to juggle surgeries through the pandemic is the “Surgical and Procedural Planning Committee,” chaired by Kingston cardiologist Dr. Chris Simpson, former president of the Canadian Medical Association.
Simpson said the province has moved past the peak of what is expected to be the first of several pandemic waves. The health system will need to be nimble and agile to deal with flare-ups, he cautioned.
“As we prepare to ramp up our scheduled and elective procedures and surgeries, we have to maintain our readiness to ramp back down if needed,” he said.
Simpson likened the halting of elective surgeries on March 15 to shutting off a light switch.
“But now as we prepare to start up again, it has to be more like a dimmer switch. Different hospitals may be able to turn the dimmer switch more than others. And just as importantly, we need to be able to dim things down quickly if needed,” he said.
Hospitals have created “surgical and procedural oversight committees” to conduct feasibility assessments on the ramping up and down of surgery. Decisions are being made with regional and sub-regional COVID steering committees. Plans are re-evaluated weekly.
Before hospitals can resume elective surgeries, they must have stable supplies of personal protective equipment and medications, adequate staffing, and sufficient bed availability including in intensive care units.
With patients’ health and lives at stake, Dale said extreme caution must be exercised as the health system continues to grapple with the pandemic.
“The COVID-19 pandemic is a lot like diffusing a bomb. A single mistake or misjudgment can have catastrophic consequences,” he said.
At Sunnybrook, Ashamalla and his colleagues have been using a complex triaging system to make decisions on delaying and rescheduling surgeries. It involves daily virtual cancer conferences with a team that includes medical and radiation oncologists, radiologists, geneticists, nurses and pathologists.
Last week, Sunnybrook began re-opening closed ORs. It now has six running and next week three more will open.
Priority is still being given to patients whose prognosis could change in four weeks.
“I truly think we have done a good job with cancers,” Ashamalla said. “I can say with a fair bit of confidence that over the course of the last four to six weeks, peoples’ cancer prognoses did not change at Sunnybrook.”
With a growing surgery backlog, the opening of more ORs is coming at just the right time, he said.
“I have a sense of urgency because I know my patients are waiting and I know there is going to be a breaking point when prognosis will change. I know we are not there yet and I know we can avoid it,” he said.
On Wednesday, the day after her surgery, Sadowski said she would have to wait another couple of weeks to get a better idea of her prognosis. That’s when she will get the pathology results.
“Shady was optimistic so I will hang onto that,” she said.
“It will be behind me only when my lymph nodes are clear and I am officially cancer free. But at least we got it out so that is the largest part of the battle.”
“As we prepare to ramp up our scheduled and elective procedures and surgeries, we have to maintain our readiness to ramp back down if needed.” DR. CHRIS SIMPSON CARDIOLOGIST AND FORMER PRESIDENT OF THE CANADIAN MEDICAL ASSOCIATION