The global outbreak of COVID-19 has disrupted many aspects of healthcare delivery - cancer prevention and care are no exception [1]. The pandemic has exposed the vulnerability of our healthcare systems, our societies, and our health, as well as exacerbated inequalities within and between European countries. It has also cast a spotlight on the vulnerability of people living with cancer.

Cancer patients are among the most vulnerable, as they may be at higher risk of serious illness and death from COVID-19 [2] [3][4] [5] [6]  because their immune systems are often weakened by cancer and its treatments, and patients are also directly exposed to disruptions in healthcare services.

As the lockdown scenario across Europe has persisted, the knock-on effects to cancer care grow ever more evident and urgent. Screening and treatment delay are very real concerns for citizens and patients. Recent estimates indicate that delays in cancer treatment and diagnosis are likely to increase the indirect death toll of COVID-19 by several thousands in the years to come [7] [8].

In addition, even before the COVID-19 outbreak, the cancer burden was on the rise in Europe - with the annual number of new cancer cases projected to increase from 3.9 million in 2018 to 4.7 million by 2040 [9].

Due to the high and increasing number of cancer patients and survivors, public authorities must take urgent measures to protect their well-being and ensure access to vital services during this time of crisis and in future attacks of severe infectious diseases.

Challenges in protecting cancer patients and safeguarding access to prevention and care

There are several key challenges to overcome:

1. Delays in cancer diagnosis and referrals caused by (i) patients struggling to secure appointments due to re-prioritised health systems, (ii) screening services being put on hold or (iii) individuals deciding not to seek care due to fear of contagion at the hospital or doctor’s office. In the months to come, this will lead to increased mortality, worsening of patients’ physical and mental health and greater pressure on health systems that can only operate at limited capacity.
2. Interruptions and delays in the delivery of different interventions has compromised patient safety and the efficacy of their treatment. Patients experienced disruptions in the supply of medications (including anaesthetics and curatives), discontinuation of chemotherapy and radiotherapy as well as of the operating capacity of hospitals. 
3. Lack of communication between patients and healthcare professionals, including supportive care workers, and between hospital care and home care. During the lockdown, patients in need of consultations and supportive and palliative care services found themselves isolated from both health professionals and their caregivers. In addition, caregivers were not able to visit patients at or accompany them to the hospital. Interruption of these services (incl. rehabilitation and psycho-social support) caused further harm to patients’ mental and physical condition and recovery.

ECL call for action to national governments and the European Commission

The Association of European Cancer Leagues (ECL) urges national governments and European policy-makers to take action to protect citizens, cancer patients, survivors and caregivers by addressing the issues stated below and following our recommendations in order to mitigate the negative impact of the pandemic on timely access to quality diagnosis, treatment and supportive care services for those who need them, now and in the future.

ECL recommends that the relevant EU and Member State institutions should:

1. Provide free personal protective equipment (PPE) supplies to all healthcare professionals caring for patients across the entire cancer care pathway - from diagnosis, e.g., professionals engaging with citizens though systematic cancer screening programmes, to supportive and palliative care. Use public procurement to ensure adequate supply of PPE in all Member States.
2. Regularly test healthcare professionals, essential workers and vulnerable populations (including cancer patients and caregivers) and support policies to enable safe return to work and educational settings.
3. Develop, validate and regulate e-health systems which can be used to monitor symptoms and support treatment and care at home. Provide tools to inform the efficient resumption of treatment and preventative services overcoming the backlog created by the crisis. 
4. Strengthen communication between health professionals, patients and public authorities regarding efficiency, efficacy and safety of health interventions’ delivery. WHO and key relevant stakeholders should be engaged to support health systems in their efforts to stress the importance of early diagnosis and population-based cancer screening (for colorectal, breast and cervical cancers), and encourage the public to act on the early warning signs and symptoms of cancer. 
5. Ensure continuous access to medical consultations and psycho-social services (incl. rehabilitation) both at health facilities and online (e-consultations). Build trust in covid-free environments in hospitals and care centres. Consider enhanced role of informal (family) caregivers in the organisation of cancer care.
6. Develop European prevention and management plans to address medicine shortages, together with the European Commission, European Medicines Agency, EU Member States and other stakeholders. Ensure early warning system and strengthen and reinforce reporting obligations for medicine developers and wholesalers to supply the market.
7. Assess the impact of the COVID-19 pandemic on:
   
   1. Potential declines of cancer diagnoses and increase in stages of cancers at diagnoses and mortality rates;
   2. The quality of life of cancer patients, survivors and caregivers;
   3. Patients’ and household’s socio-economic conditions;
   4. Health systems’ capacity (including cancer screening, early diagnosis and palliative care);
   5. Investment and delivery of cancer research.
8. Provide equitable support for countries in Europe prioritising those countries with limited resources and strained health systems. Resources from the EU4Health programme (2021-2027) and Coronavirus Response Investment Initiatives funds must be front-loaded to ensure quick and targeted interventions are made to protect cancer patients and to prevent a negative impact in the delivery of cancer services during epidemics.   
9. Exploit Horizon Europe to support research towards monitoring the long-term impacts on cancer patients and caregivers, considering the psychosocial and economic burden alongside the potential consequence for cancer mortality.    
10. Ensure equitable access to affordable COVID-19 vaccines in Europe, with most of the investments in vaccine R&D coming from public funding. 

ECL calls upon all decision-makers to stay alert and continue to behave responsibly towards their citizens. Governments should prepare health services for the case of possible future emergencies.

About ECL

The Association of European Cancer Leagues (ECL) is a non-profit, pan-European umbrella organisation with the mission of uniting national and regional cancer leagues to achieve a cancer-free Europe. Active since 1980 and located in Brussels, ECL currently has 29 members from 24 countries, covering 21 EU Member States. ECL’s members are cancer charities operating across the whole patient pathway - from cancer research and awareness to patient support during and after diagnosis. Cancer leagues are the main resource for the public for cancer control information and services. ECL’s mission is to influence and improve cancer control and cancer care in Europe. This is done by providing a forum and voice for experienced charities and supporting new entrants facilitating collaboration and knowledge sharing, primarily in the areas of cancer prevention, tobacco control, access to medicines and patient support, as well as creating opportunities to advocate for these issues at the EU level.

www.cancer.eu | @CancerLeagues

Wish to discuss ECL's Call for Action further?

Contact the ECL Secretariat at ECL@europeancancerleagues.org

References

[1] World Health Organization (2020) ‘Rapid assessment of service delivery for NCDs during the COVID-19 pandemic’. https://www.who.int/publications/m/item/rapid-assessment-of-service-delivery-for-ncds-during-the-covid-19-pandemic

[2] Liang, W. et al. (2020) ‘Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China’. Lancet Oncology. DOI: https://doi.org/10.1016/ S1470-2045(20)30096-6

[3] Wang, H and Zhang, L. (2020) ‘Risk of COVID-19 for patients with cancer’.

Lancet Oncology. DOI: https://doi.org/10.1016/S1470-2045(20)30149-2

[4] Kuderer N.M. et al (2020) ‘Clinical impact of COVID-19 on patients with cancer (CCC19): a cohort study’. Lancet. DOI: ohttps://doi.org/10.1016/S0140-6736(20)31187-9.

[5] Tian, J. et al. (2020) ‘Clinical characteristics and risk factors associated with COVID-19 disease severity in patients with cancer in Wuhan, China: a multicentre, retrospective, cohort study’. Lancet Oncology. DOI: https://doi.org/10.1016/S1470-2045(20)30309-0.

[6] Yang, K. et al (2020) ‘Clinical characteristics, outcomes, and risk factors for mortality in patients with cancer and COVID-19 in Hubei, China: a multicentre, retrospective, cohort study’. Lancet Oncology. DOI: https://doi.org/10.1016/S1470-2045(20)30310-7.

[7] Lai, A. et al. (2020) ‘Estimating excess mortality in people with cancer and multimorbidity in the COVID-19 emergency’. ResearchGate.DOI: https://doi.org/10.13140/RG.2.2.34254.82242

[8] Sharepless, N.E. (2020) ‘COVID-19 and cancer’. Science. DOI: https://doi.org/10.1126/science.abd3377

[9] GCO IARC (2018) ‘Cancer Tomorrow’. Available at: http://gco.iarc.fr/tomorrow/home (all cancers excluding non-melanoma skin cancer, both sexes, all ages, in Europe) [cited 2020 Jun 28].