Coronavirus: what are the implications for cancer patients?

Grandstand. With the coronavirus, we are living much more than a health crisis. It is also a test of resistance for our health systems, even for the countries considered as “best ranked” by the various evaluation institutes or bodies. The indicators used, such as economic performance criteria, minimization of the cost of production, satisfaction of a standard of equity specific to each company, now appear to be poorly calibrated and insufficient in the face of such an epidemic crisis. As this pandemic progresses, we understand less the absence of indicators relating to the conditions of practice of those who provide care and to their dedication.

The fight against Covid-19 goes beyond a fight against the epidemic. It is also a struggle to maintain care for other chronic or acute pathologies that have not disappeared during this epidemic period. No one can also conceal the social and economic consequences, possible obstacles to access to care for all. An estimated 3.5 million French people are affected by cancer in France and 382,000 new annual cases in 2018, i.e. around 1,450 new cases diagnosed every day of the week. The Minister of Solidarity and Health regretted that cancer screenings were no longer carried out, “Calling the French” to return to their doctor for these diagnostic procedures. This announcement is important but may not be sufficient or essential to avoid the potential serious consequences of delayed or unannounced diagnoses, treatments degraded by necessity, renunciations of care or the interruption of inclusions in therapeutic trials.

A national strategy to be implemented

It would now be necessary to quickly implement a coordinated national strategy with a coherent territorial variation adapted to the local epidemiological and health situation, even when efforts are made to limit the spread of the virus by containment and barrier measures. The paradox of our society overdone with inflationary regulations and saturated with organizations of all kinds, but which ultimately finds it very difficult to organize or impose cooperation in this unprecedented context. Yet we have entered a period when things that once seemed impossible are inevitable.

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Since the epidemic crisis and the post-containment period are expected to last several months, the fear of the medical community with which I associate and of the nursing staff of my establishment specialized in the fight against cancer is that we are faced with a first “wave” of more serious cases than before linked to deferred care. After this period of crisis, the duration of which no one can seriously determine, health facilities that have been under tension for many years may find it difficult, especially if they have been considered as “Covid-19 hospitals”, to be absorbed into reasonable times the care of patients awaiting treatment as well as the flow of patients with newly diagnosed cancer reintegrating a course of care. It will most certainly take months to restore optimal organization. In addition, even if the epidemic crisis ends, the deterioration of the economy could accentuate inequalities with all its consequences on access to healthcare, particularly in the case of cancer.

Towards an increase in mortality?

For breast cancer, the most frequent cancer in women, whose annual number of new cases is estimated at 54,000 in France, the surgical management of patients with favorable prognostic criteria has been postponed, in accordance with the opinion of the High Council of Public Health available from mid-March and on the recommendations of learned societies. Even if these are remarkable recommendations which are unanimous during this period, it should not be forgotten that these are expert agreements for degraded care which should not last, at the risk a loss of luck for patients with even cancer said to have a good prognosis. Other examples could be taken, such as pancreatic cancer, the incidence of which has more than doubled over the past twenty years and whose unfavorable prognosis means that any delay in diagnosis by limiting access to radiology services, that any delay in surgical management due to the absence of an available operating theater or access to post-operative resuscitation could inevitably lead to an increase in mortality.

The Lombardy region of Italy, very affected as everyone knows by the pandemic, has managed to organize itself to maintain adequate care for cancer patients during this epidemic plague. Several platforms (HUB centers) have been set up, dedicated solely to the treatment of cancer patients (including the European Institute of Oncology and the National Cancer Institute in Milan). They receive newly diagnosed surgical candidates from area hospitals more dedicated to treating Covid-19 patients. These Covid-19-free cancer hospitals can continue to care for cancer patients even if they are small cancers with good prognosis.

This attention-grabbing pandemic should not make us lose our minds. After having wagered on economic performance for years, we suddenly moved on to the almost exclusive total fight against the Covid-19. It must be remembered that there is a middle way in everything that avoids extreme attitudes while preserving the future.

Emmanuel Barranger Surgeon oncologist, director general of the Center for the fight against cancer Antoine Lacassagne, Nice (Fédération Unicancer)


Coronavirus: “Everything contributes to the virus circulating on the African continent”

After being head of the infectious diseases department at the Saint-Antoine hospital in Paris, Professor Pierre-Marie Girard is now the Director of International Affairs at the Pasteur Institute in the capital and head of the International Network Instituts Pasteur, 10 of which are located in Africa.

The great fear around this new epidemic was that it would reach Africa. However, there is only one known case, in Egypt. Is this good news?

Today, no one understands why the epidemic has not yet developed on the African continent. Many experts doubt the reality of the figures displayed. The most optimistic are surprised but they bet that the epidemic will end before the African continent is hit. For pessimists, there are two possibilities: either cases have not yet been identified and it is only a matter of time, or the ever-increasing evolution of the epidemic in China, the inevitable flaws in the measures isolation and the extent of their constraints will necessarily lead to an extension of the epidemic to Africa.

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Why is there such a strong doubt?

A simple observation: in Africa, there are more than a million Chinese nationals who go back and forth to their country, and there was, in addition, a strong movement around the Chinese New Year. Everything contributes to the virus circulating. Moreover, on Wednesday, there was a remarkable modeling done by an Inserm team around the Italian researcher Vittoria Colizza showing that Egypt, Algeria and South Africa would be the gateways to the most likely of the coronavirus on the African continent. To do this, they worked on the importance of air traffic with the contaminated Chinese provinces, pointing to the large air hubs through which many travelers pass. These three countries are also among the best equipped on the continent to quickly detect and deal with new cases. In other African countries, according to this research, the risk of importation is lower but the sanitary deficiencies can raise fears of a rapid diffusion.

In this case, what explains the absence or almost no case?

It is possible that there are hidden cases, infected people who did not have access to the tests or, above all, people infected during the incubation period, therefore not detectable. The most likely assumption is that the coronavirus is circulating at least quietly.

Maybe the climate is not suitable for this virus?

No. The tropical climate is not a powerful brake on the replication of coronaviruses although a partial seasonality is likely as for most respiratory viruses. To bet on climate protection in Africa or spontaneous control of the epidemic at the end of winter would be absurd.

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What should be done, however, for Africa?

Prepare, and, as is the case in many African countries, with the support of international aid. With our 10 institutes, we were able to make molecular tests available as soon as they were developed. Reference centers were equipped and biologists trained from mid-January. Fortunately, infected people are mainly contagious during the first symptoms, which makes it possible to identify the people most at risk, those who can even be severely affected and transmit the virus to those around them. This allows you to act more efficiently and quickly limit the transmission.

Still, in your eyes, there will be an epidemic in Africa anyway …

In any case, nothing is finished. The epidemic is not currently under control in China, it is not known how long people will remain contagious, and as in any epidemic, there can be rebounds after phases of relative lull. It will last for months. Perhaps the worst is ahead of us. But if the worst is never certain, it would be collectively unacceptable not to prepare for it and thus ignore the risks run by the poorest countries.

Eric Favereau