As the race for a vaccine for COVID-19 continues, many healthcare professionals are on the frontlines in the hospitals and observing how the pandemic is impacting various aspects of healthcare. We recently invited two of our colleagues to share their perspective on the ways that COVID-19 is impacting cancer care.
Dr. Parham (left) is the professor of gynecologic oncology in the department of obstetrics and gynecology at the University of Zambia and University of North Carolina at Chapel Hill and Dr. Dorothy Lombe (right) is a Clinical Oncologist at Cancer Diseases Hospital in Lusaka, Zambia.
The two sat down to answer a few questions, and we want to share their conversation with you.
1. What are the positive changes with regards to cancer care you have observed as a result of the pandemic? Dr. Parham shared, “I think there’s been more virtual management of cancer cases and our focus has been changed to building robust and sophisticated telecommunications networks. It has forced us to slow down and reflect and to make sure that the time we spend is more focused on quality than quantity. It has made us take time to make sure that when we do interact with our colleagues and patients we really get to the meat of the matter. I would say that in terms of human interactions it has caused us to be more efficient, because the amount of time allocated to virtual contacts is limited.
From a research perspective another benefit is that it has caused us to be more innovative. For instance, we have several cervical cancer screening research projects in Zambia, and we recruit study participants from the general screening population. The COVID pandemic decreased the number of women who were coming in for general screening, so it forced us to explore new avenues to increase our general screening population in order to maintain study recruitment levels. We formed new partnerships with traditional healers, commercial sex worker organizations and health facilities in the private sector in order to increase access to populations of unscreened women. We can build on these new relationships in the future once the COVID pandemic is over.
2. What negative changes to cancer care do you think have resulted from the pandemic? Dr. Parham: “Dr. Parham: “I think the main negative effect is the lack of person-to-person contact. There’s something that we miss from seeing and touching and feeling and being close to another human being. And there’s lack of safety in the workplace. You always want to feel comfortable coming to work and when you are frightened, and forced to wear masks, it just doesn’t feel the same.
One of the other big problems is delays in patient therapy. I’m a gynecologic cancer surgeon- here at the University Teaching Hospital in Zambia we’ve had to change the way in which we prioritize patients for cancer care to those who are severely symptomatic. Therefore, some of the patients who would have benefitted from early intervention, such as those with early stage ovarian cancer, early stage endometrial cancer, small lesions on the vulva, early-stage cervical cancers; things that we usually pursue aggressively. We’ve had to deprioritize the treatment of these patients to treat those that are more symptomatic, i.e., women who present with severe vaginal bleeding or with massive abdominal ascites from advanced ovarian cancer, etc. So, we may lose some of the early stage cancers because of delays in therapy and lost to follow up.”
3. Do you think we should maintain those positive changes after the pandemic?
Dr Parham: “One of the issues needed in cervical cancer control is monitoring and evaluation and quality assurance of the things that the providers do. This aspect of cancer care has lagged behind as screening services have been scaled across the country. The experts that are needed to perform these tasks would have to travel long distances and they would they would thus be unavailable to perform their regular jobs. We are now looking towards using telemedicine and virtual-based communication to perform quality assurance. Because this form of communication has become so popular during the COVID pandemic there is much less resistance to it now, than there would have been in the past. Telemedicine now is a part of everybody’s vocabulary.
I think we need to really accelerate this new form of communication, particularly in Africa. There is now a great opportunity to move Africa forward in terms of building this kind of telecommunications and infrastructure network. So, I think we should embrace it wholeheartedly.”
4. What other barriers will prevent changes from happening? Dr Parham: “I think cost and just trying to figure out how to make it happen. Our internet system is probably not as robust as it needs to be. The basic internet infrastructure is going to have to rapidly improve in order to carry the weight of this new form of communicating in medicine and figuring out how to safeguard patient identification.”
5. In Zambia at the Cancer Diseases Hospital, what are the positive changes with regard to Cancer Care have you observed as a result of the pandemic?
Dr. Lombe: “The positives I think, for us have seen a lot of shift. I think that telemedicine is really a positive thing. We are moving to a virtual platform and I feel we do have solutions even in places like Zambia where you’ve got rural areas that don’t have access; you still have infrastructure like at district hospitals or you know, at places where you could have a central place for a person to actually access that rather than travel the whole 12,000 kilometers to the central place.
I was actually in a bank the other day and I noticed that the banks have booths where if you don’t have internet at home, you can actually access internet in those booths. So in a similar way medicine can do that, you could have these peripheral centers with these booths where villagers could come and access this type of help without traveling long distances. So telemedicine is definitely something that we should move to and I’m also excited about telepathology.
I think that the processing room should actually move more to the clinic area, and we’re actually just sending these prepared slides out to the pathologist. So that is definitely a positive.
The other, the other big thing I think the COVID pandemic has taught us is value. We have learned how to survive with the bare minimum and we have learned how to say what is really valuable for this patient, which I think cancer is really a culprit. Our field is a culprit of you know going for the tiniest bit of the benefit, because it’s such a scary disease and people will throw whatever they can for that extra one month and even if we know that one month isn’t really valuable. We’ve forcibly done it. Even if we know that an extra fraction of radiotherapy doesn’t really add it we’ve taken so long to change from twenty gray in five fractions to eight gray single for palliation, which numerous studies told us before that. They were equally effective. So the fact that we have now created a value-based system- I think we should maintain it. You know, we should not go back to giving patients unnecessary treatment everything. You know for the first time I’ve seen Zambians say we’re not going to give chemo because you know, I was always trained to say when you’ve got an ECOG status of three, you don’t give that patient chemo. But in Zambia we say it’s a cultural thing, but because of the pandemic, people have come to accept that no, this patient actually would be better off on pain control, symptom management, and we don’t need to give this patient anticancer drugs that we know I just going to reduce their quality of life. Value-based oncology care has really come out during the pandemic.
The other thing that is also very basic but something that was lacking was the hygiene practices. The simple cleaning of the institution and ensuring that twice or three times a day, everything is clean that had really taken a dip. But with the COVID pandemic accounts all of a sudden do understand the value of disinfectant because they are equally affected so as a side effect we practice cleaning. It’s something that is so basic but it’s something that is highly lacking in our institutions.
Lastly for me what also came out was the mental health of workers. Already healthcare professionals in low-income countries suffer from a lot of moral distress because you know what you’re supposed to do for the patient, but you don’t have the resources and for a long time nobody really listened to this distress. The COVID pandemic shut people down and actually made the management or the leadership of the hospital actually pay attention to the mental health of workers. This makes a massive difference because healthy, mentally healthy workers are compassionate and patient and that’s what a lot of our patients need. Most of our patients come in with locally advanced cases and there’s really nothing much you can do for them. Having a workforce that feels valued and is taken care of mental health wise is something that we need to keep up and we need to continue having access to psychological services and so on.”
6. What would you consider a barrier to change in Zambia? Dr. Lombe: “I think I would echo your opinion in that costs, you know everything has a cost. Secondly, I would say attitudes. We often overlook attitude because after some time, you know, we saw it when the first wave was going down people kind of relaxed. Now the second wave has hit us bad and prominent people are actually dying and all that again we’ve lifted up our guard. So we have already seen that attitudes can dismantle things that have been well built, even when you think are robust and sensible. Attitude is something that is one of the greatest barriers.”
We are thankful for our frontline workers and all that they are doing to breakdown barriers and provide access to healthcare for women across the world. Listen to the full conversation here
To learn more about their efforts and research, please visit their websites below.
Dr. Dorothy Lambe: https://dorothylombe.com/
Dr. Groesbeck Parham: https://www.med.unc.edu/obgyn/directory/groesbeck-parham-md/