The Effects of COVID-19 on PMP Services Around Europe

Around the world, the COVID-19 epidemic has been hitting our health care systems very hard. Intensive care units have been inundated with patients requiring careful, around-the-clock care. Physicians have been transferred from their normal duties to hastily set up critical care wards within their districts to try to treat the vast numbers of affected patients. Nurses have been sent out to test patients in temporary drive-up clinics, and biologists and lab workers have had their normal duties re-directed to include testing the enormous numbers of patient samples incoming daily from worried patients.

We have heard much about the effects on primary care physicians and clinical specialists, but we have not really heard very much about the knock-on effect of the undertakings on the specialist clinics and surgeries. Within the EuroPMP COST Action, many physicians and surgeons have had unusual situations and new protocols imposed on them in order to deal with the threat the virus poses to their vulnerable patients. We thought it might be interesting for everyone to see how thing are going around Europe, so we asked a few of our colleagues to share their viewpoint on the crisis from the perspective of their own country. The following responses were collected over two weeks in April 2020, and minimally edited for clarity where necessary. We hope that they will be interesting to everyone!

■ Bosnia and Herzegovina (Edina Lazovic)

“Bosnia and Herzegovina has a population of 3,79 million. The COVID-19 pandemic was confirmed on 5 March 2020. As of 9 May 2020, in Bosnia and Herzegovina, there were 2,093 confirmed coronavirus cases, with 102 deaths and 1,083 recoveries. On 17 March 2020, the Council Ministers of Bosnia and Herzegovina declared a state of emergency in all of Bosnia and Herzegovina.

I work at the Department and Institute of Pathology at the Faculty of Medicine in Sarajevo (Capital of Bosnia and Herzegovina) as an assistant professor. Classes for medical and dental students have been transferred to the online system. We perform pathohistological diagnostics of biopsy samples continuously. We are divided into teams and work weekly so we come to work every 15 days.

The medical school has offered its staff to help the Corona Virus Clinic but there is still no need for that. We have not yet returned to the “normal“ service.”

■ Germany (Beate Rau)

The crisis has no impacted services delivered a Beate’s clinic, nor have any changes to service delivery been made during this critical time. Beate indicates that because of the low frequency of surgical oncology, she hasn’t had much to do! Patients have not experienced any changes in the service delivery. Germany is well on track toward getting back to normal service delivery in their hospitals. We wish them good luck in the process!

■ Ireland (Jürgen Muslow)

“After an initial complete pause of approximately two weeks for all surgery, we are slowly starting seeing patients in clinic and performing surgery for PMP and other cancers. Our clinic model has moved to a virtual system (telephone or video call) for most patients. For patients with PMP for whom a decision has been made to proceed to surgery, we then review them in an isolated clinic prior to admission for surgery. We are now running at full capacity for peritoneal malignancy, including PMP, however all non-urgent surgical activity remains largely suspended.

Thankfully I never needed to move outside of my surgical practice. Some of our more junior staff have however been redeployed, mainly to cover other medical staff who were self-isolating. These staff are now starting to return to the surgical service. A lot of careful planning was undertaken throughout our hospital which has thankfully meant that we have never been overwhelmed with COVID patients.

Our experience is that patients have been extremely understanding and accepting of any delays they have encountered. Thankfully we have been able to maintain all of our usual lines of communication for them to contact us if needed.

COVID admissions have been stable and under control for some time and we are starting to plan how we will deliver more routine surgery, accepting that we will not be returning to practice as we knew it pre-COVID.  There will be very many challenges due to existing backlogs and the build-up of patients who currently are unable to enter the system. We also recognise that our capacity will be significantly reduced as we work alongside COVID with the need to maintain social distancing, increased turnaround time between patients due to sterilisation of rooms, theatre etc. We do not have the answers to many of these problems yet.

One plus has been an increased time for preparation of research papers and development of other aspects of our service.. the things we would normally struggle to find time for.”

■ Israel (Aviram Nissan)

“Currently (May 8th, 2020 update), Israel was mildly affected by the COVID-19 pandemic with 16,406 confirmed cases, (1893 cases per 1 million population) and 242 cases of death (26 cases per 1 million of population).   First documented positive patient in Israel was diagnosed on February 27, 2020.

In March 12, 2020 all schools and non-essential work facilities were closed as part of the effort to control the outbreak.

Starting on March 22, 2020 all medical institutions initiated a strict emergency protocol where all elective procedures, except certain oncological procedures were postponed. During the outbreak period, additional strict national preventative measures for social distancing were implemented. As a result, accessibility to medical care in the community was limited.

Sheba Medical Center is a tertiary referral center in a university hospital setting that provides service to an area with more than 1.5 million citizens and is the largest hospital in Israel. Sheba Medical Center was assigned to lead the national effort against COVID-19. A “Corona Hospital” was opened with dedicated ICU and step-down unit (70 beds), a specialized COVID-19 Unit (43 beds) and additional internal medicine, pediatrics, maternity and psychiatry wards capable of maintaining 400 COVID-19 patients with a capacity to ventilate more than 200 patients. These dedicated COVID-19 units were located outside the main hospital building, allowing, together with strict isolation policy for patients and medical personnel, to maintain all resources for emergency as well as cardiac and oncology activities.     During the COVID-19 outbreak, we have noticed that public seemed to avoid visits to the Oncology Institute fearing of exposure to infected patients, and those who eventually arrived appeared to be in worse physical condition.

Although, tumor board meetings were continued by video-conferencing “Zoom Meetings”, we also noticed that treatment altering decisions were less likely to take place.

We are currently analyzing the impact of the COVID-19 outbreak on cancer surgery.

A prospective real-time Surgical Oncology Registry identifying all patients operated on for cancer between March 15nd and May 1st 2020 in our center was performed (COVID-19 group, the study group). The study group was compared to patients admitted in the parallel time period (March 15th, 2019- May 1st 2019), pre COVID-19 era, (Control Group). The study was approved by the institutional review board.

Preliminary results show that major cancer surgery (Gastro-intestinal tract, sarcoma, PMP) was not affected. Minor cancer surgery such as breast and melanoma decreased in numbers.

As for research, our lab (The Surgical Oncology Laboratory) continued to collect tissues from the operating room. Since the entry to the operating theater of non-essential personnel was restricted, specimens were carried to the lab by the surgeons.

We had to temporarily shut down the organoids project due to lack of supplies. We took a major effort constructing a model of infectious bronchitis virus (IBV), an avian coronavirus, almost similar in structure to SARS-Cov-2 virus affecting humans. This model provides us with a tool to investigate new therapeutic agents against COVID-19 in a chicken embryo model (previously used to test anti-cancer agents). In the future, we will use this model to develop gene therapy against various peritoneal surface malignancies including PMP.”

■ Latvia (Andrejs Pčolkins)

“Fortunately, Latvia has shown very good results in fighting COVID-19 spread. Our epidemiologist and infection disease specialists have learned from mistakes made by other European country authorities and implemented almost full lockdown when Latvia had only 2 positive cases. We were expecting the worst scenario like it happened in Italy, Spain, UK etc. and people were frightened. From the 12th of March all schools and most of kindergartens were closed. We were not allowed to gather more than 2 people with 2-meter distance, unless they are living or working together. Gyms, playgrounds, museums, cinemas etc. are still closed. Meanwhile, people were not forbidden to walk outside, going for shopping and restaurants (strict 2m rules!). Finally, it is more than 10 weeks since the first COVID-19 case was diagnosed and up until now there were 1,006 cases with only 19 died of coronavirus. So we feel that epidemic is fully controlled inside our country and for the last few weeks we are almost back to normal life.

Regarding health services there were some nasty restrictions: 1) All private services were closed for 6 weeks, unless it was oncology, emergency or obstetrics; 2) Non-essential outpatient clinics were cancelled; 3) Hospitals were continuing serving only oncology, emergency and obstetrics services; 4) Most of the emergencies were diverted to small district hospitals and main hospitals left half empty; 5) All COVID-19 patients requiring admission were sent to dedicated Infectious disease centre and only those who had other medical issues (medical, surgical..) were admitted to Riga East University hospital; 6) All patients admitted to our hospital were tested for COVID-19 and isolated on the ward till the final test been reported; 7) For those who have turned out positive, surgery was postponed, and all contact persons were quarantined for 2 weeks, doctors as well.

I am working in Latvian Oncology centre and all our patients are at the highest mortality risk for COVID-19. Luckily we have identified only 3 patients and 4 medical workers at our institution  – so we were able to control and prevent further spread. However, there was major disruption in medical services at all levels – prophylaxis, screening and even emergencies were put on hold for some time. Right now we are experiencing some COVID-19 indirect consequences – emergencies are more severe, delayed diagnosis of cancer with advanced stages, limited diagnostic options. Many patients are cancelling their clinical appointments and definitive treatment.

Our government have extended lockdown until 9th of June, but with much softer restrictions – we are allowed to gather in groups up to 25 people; kindergartens are open; gyms, shopping centres, playgrounds are opened. All elective, private and NHS services are reopened.

Finally, I would like to say that Latvia is doing very well in terms of controlling Covid-19 spread.”

■ North Macedonia (Jasmina Simjanovska)

“The COVID-19 pandemic has dramatically changed the way our health care system has been functioning. The changes are obvious in all areas of the health system institutions’ operations.

Due to COVID-19, the change in the general functionality of the Macedonian health care system may be identified in the high importance placed on change in medical services, management, education, practices etc.”

The Government of the Republic of North Macedonia put extra measures in place to prevent the spread of the virus, including self-isolation for anyone returnin from high or medium risk countries for a period of 14 days, in accordance with the WHO recommendations. Export of medical equipment and supplies made by manufacturers inside the Republic of North Macedonia was stopped, unless special permission is obtained. As well, older people and citizens in high-risk groups have been asked not to use public transport and to limit their movements to avoid being exposed to the virus.

Previously, on 11th March, the Government had stopped people with chronic respiratory diseases, severe cardiovascular disease, type 1 diabetes, malignant diseases and immunocompromising diseases to be exempt from work with doctor’s note. Vacations and all other types of leave were cancelled. The government set up a special hotline for patients to call to get information and answers about COVID-19, and special messages were sent out to citizens giving recommendations about copin during the crisis.

Border restrictions were put in place on 14th March which required the Ministry of Health to issue a written quarantine order on all citizens returning to the Republic of North Macedonia. Returning citizens have to sign the order and give a fixed address they will be living at. The order places that person under obligatory self-isolation, which carries full moral, material and criminal responsibility on the person involved.

Jasmina said, “My colleagues and I in the health system are facing the new situation in accordance with the measures and recommendations of the Government, Ministry of Health and the Infectious Diseases Committee including Internal protocols issued by the health institutions (primary, secondary and tertiary).

Within the framework, and of highest priority, there has been a critical need to create an urgent functional strategy, restructuring work on medical services in all levels, and introducing a new scheme and protocol for admission, diagnosis and observation of patients.

As part of the Institute for Pulmonary Diseases in Children, a separate department for the admission of patients with symptoms of COVID-19 was opened. Several patients have been detected.

The responsibility [to care for patients] is a great challenge in coping with the new situation, which has never been seen before. Besides daily activities, all doctors and medical staff were mobilized in order to act if the situation escalated. The pandemic is significantly reduced, it is under full control by the Institutions responsible to managing the current crises.

Timely measures taken by the Government respecting the guidelines and daily monitoring of the situation and the management of the situation by the Crisis Headquarters of the Ministry of Health have helped a lot. There have been great and transparent daily briefings with the media. Basically, the rigorous measures were respected by the citizens. Full cooperation of health care institutions has been based on available capacity.

We are facing the lifting of restrictive measure, but actually the restructured programme is still in force from 19.00 to 05.00 daily. But the lockdown is gone, and the “new normal and service life” has been created.

The future is unpredictable, but the healthy service is modified and under control.”

■ Norway (Kjersti Flatmark)

“In Norway, the service for peritoneal surface malignancy surgery (CRS-HIPEC) is offered in Oslo at the Norwegian Radium Hospital, part of Oslo University Hospital Comprehensive Cancer Center. Our unit has maintained normal activity throughout the COVID-19 pandemic, and several PMP patients have been treated. Although treatment has commenced as planned for patients with peritoneal disease, we have restricted biobanking to include PMP samples only, which is slightly different from our usual biobanking activities where we include many more patient types.

The Norwegian Radium Hospital treats cancer patients only and was designated to be a “corona-free” hospital, which means that any infected patients would be transferred to other parts of Oslo University Hospital. The personnel at our hospital has therefore generally been assigned to the normal duties.

The main difference for patients has been a strict corona triage procedure before admittance, movement restrictions within the hospital and that no visitors have been allowed. Additionally, out-patient services have been replaced by telephone consultations when possible.

Norway has started to normalize services although many restrictions still apply. Our borders are still closed, and home quarantine for exposed people is still required, and probably will be for some time to come. This has affected nursing staff in other hospitals and wards as people were quarantined if they were exposed to limit the spread of the infection. This meant that for a while, we had fewer nurses and doctors on the front lines to help incoming patients, but this has been steadily getting better over the past few weeks, and we are almost back to normal now in most hospitals.

Non-critical workers are still being asked to continue to work from home for now, although we are trying to get back to normal. We must continue to hold a 2m distance between people at work and in social activities, and we cannot have more than 5 unrelated people gathered together unless they can all maintain 2m distance from one another. This has meant some changes around the office, but in all, we are managing very well.”

■ Pakistan (Raza Sayyed)

“The first case of COVID-19 in Pakistan was diagnosed on 26 Feb 2020. Two of the neighboring countries, China and Iran had seen a significant brunt of the epidemic. In this regard, some measures were taken to control the spread of the disease. These included border closure, airport security and school closure in early March and later a Lock-down by mid-March. The outpatient clinics were initially closed in many public and private sector hospitals to gauge the extent of the epidemic as well as to prepare for resuming services. These were eventually resumed. Karachi has a population of above 16 million people but the catchment area is much more as patients from other cities from the province visit the city to access specialized care. The lockdown with closure of intercity and intracity public transport significantly impacted the ability of the patients  to access specialized care for their disease.

Patel Hospital is a multidisciplinary hospital and had not been a designated hospital for taking care of COVID patients, however, suspected patients were admitted to a specially designated area and transferred to nominated facilities in patients who test positive.

I have been part of the taskforce planning response to COVID-19 in my institution. This has initially been quite overwhelming as it required significant amount of time for planning, discussion in order to close and prepare services for resumption as well as to ensure a steady supply of PPE. Although the institution has dedicated a number of beds to diagnosed or suspected COVID-19 patients, I have not been called to serve on the area so far. However as part of the contingency plan in case of exposure/infection of the healthcare providers, all doctors in the hospital will be filling in to provide care for the patients with COVID-19.

The surgical oncology service switched its outpatient clinics to virtual clinics from the very beginning and after a few weeks gap, started once a week face-to-face clinic in which patients were vetted to be called based on “need to review” or “inability to access the virtual clinic”.

The operating room was initially restricted to emergency procedures only. Infrastructural changes were made in the operating room to allow safe performance of aerosol generating procedures. In the next step, urgent procedures were allowed subsequently followed by opening up the OR for elective surgery in carefully selected, COVID negative patients.

Although these measures have enabled us to perform procedures like CRS and HIPEC after these changes, no such procedure has been performed in our institution since the disease has emerged in Pakistan. One of the reasons being a generic recommendation from multiple fora to postpone CRS/HIPEC for peritoneal malignancies before situation improves. Another reason is an element of fear of acquiring the infection from the hospital during treatment. This is a valid concern on part of the patients as well as the healthcare providers since our hospital is not a dedicated COVID free facility. The lockdown has also had financial impact with many patient not able to support their treatment ‘out of pocket’.

Laparoscopy is still not recommended in our institution and this has impacted care of cancer patients. Colorectal cancers are not offered the advantages of minimally invasive surgery. In addition staging laparoscopy is not performed for the routine indications including evaluation of peritoneal surface malignancies.

Patients have had significant problems with interruption of care not just for surgery, but some patients have had delays to neoadjuvant or adjuvant chemotherapy or radiation therapy in different centers. This clearly has taken an emotional and psychological toll on the patients, however the impact on the oncological outcome will become evident over the coming months to years.”

■ Poland (Tomasz Jastrebski)

“In Poland, the first reaction was disbelief that such global, hazardous pandemic may happen with such a wide range. Information about the pandemic, first as local to Wuhan, then in Italy, overlapped with winter vacation. Only when tourists came back from vacation did the Government react. Because early knowledge of the gist of COVID-19 infection was very poor, administrative activities were instigated nervously and excessively.

Hospitals for infected patients were quickly enough created, and in these hospitals all planned surgery was stopped, for oncological patients too.

Because of lockdown for all who had contact with infected persons, many hospital’s departments stopped their activity for 2 weeks. In one high-volume hospital, all surgical departments were closed for 2 weeks.

For 2 months all planned surgery, except for cancer surgery, were stopped.

In oncology, many patients had problems with continuation of chemotherapy because lack of nursing personnel due to their contact with infected person, or someone just back from Italy (2-weeks obligatory lockdown).

Because risk of COVID-19 infection in many oncological ward, doses of planned chemotherapy were decreased and, in my opinion, patients were treated suboptimally.

In many surgical department staff worked in a two-shift system, so the numbers of oncological operations was limited.

But the most important negative impact of the pandemic was observed in diagnosis of oncological diseases: gastroscopy, colonoscopy, and usg practically stopped and are not available for patients. There is a better situation for MRI, CT or PET diagnosis.

The worst situation is in hospices – the most doctors and nurses worked in these as a secondary workplace. Because all health system personnel must work in only one place during pandemics, many hospices and retirement homes were deprived of professional health care. It is changing slowly, but it is still far from stable.

As of now, it is not possible to perform any planned surgery other than oncological.”

■ Portugal (Andreas Brandl)

“It is very difficult to stay a COVID-free institute, and I honestly agree, that nobody can really be sure about that, as many patients spread the disease during their asymptomatic phase. Maybe I explain a little bit better, how we try to reach it.

Portugal’s basic measures have been comprehensive and clear. Andreas stated, “Every entrance (we only have two) of our building is secured by nurses. Every person who wants to enter the building gets his/her temperature measured (infrared) and questioned about his health status (cough, tiredness, cold, etc.). Every person is obliged to wear a mask inside the building. Nobody (family/relatives) is allowed to accompany outpatients, in case of the need of physical assistance, we provide service by nurses to accompany the patient. In case of dementia, etc. one relative is allowed to accompany.

Oncologic outpatient care was minimised to either patients receiving treatment (chemotherapy) or patients with the need of a physical consultation/examination (e.g. wound care, removal of stitches, vaccination, etc.). The rest of the patients (regular oncologic follow-up visits) are consulted via videoconference during the consultation hours.

Inpatients have to have proof of a negative COVID test less than 48h prior admission, in our case for surgery. Postoperatively, every patient gets a COVID test once per week, which is in most of the cases one test after surgery.

Health care professionals are not routinely tested. We minimise our presence at work, as ward rounds and MDT meetings are only performed/attended by one surgeon. “

■ Sweden (Peter Cashin)

At the time of writing, the crisis has not really impacted the services delivered in clinics in Sweden. Peter says “We have basically the same amount of operating time. It hasn’t affected our ability to do the Clinical side of things. Research wise, inclusion into new studies has been difficult also for HIPEC. Some studies have been suspended temporarily during a few weeks. However, we are now trying to push through the studies as planned, but inclusion was stopped completely for a few weeks. Can’t remember exactly how many weeks.

I have worked 3 Days on a COVID ward. So the burden to help out has been light. It has affected our younger residents much more so it has been a more difficult for residents than specialists.

Peter noes that he hasn’t had many issues with patients. He notes, “We have had one patient come down with COVID forcing his surgery to be pushed forward, but only otherwise we have been able to keep basically the same production level.

Things are slowly going back to normal. Our hospital has already shut down one of the extra ICU COVID wards (out of 3). In 2-3 weeks, 2 more COVID cohort wards will also close. So it is slowly getting back to normal but not quite there yet.”

■ Turkey (Emel Canbay)

“My practice in both out-patient clinic and inpatient service including surgery was heavily affected by the SARS-CoV-2 pandemic. My surgery was completely stopped. At beginning of March, I returned back to my country [from Japan] and had to have a quarantine for 14 days. I had two PMP cases already planned for surgery. One of them was from Istanbul while another was from outside of Turkey who underwent systemic chemotherapy. I had two more who were operated on recently. They are still waiting. I only added COVID rapid test and IgM and IgG tests before surgery.”

Emel has not been called on to serve in the coronavirus wards, but this has still been difficult for her patients. Emel said, “The patients were so sad and did not know what they had to do, even if I have left great time to control their mental health. I have close contact with them. I have already added anti-depressants too.

In my country all elective surgeries were stopped except emergency and cancer surgery in the end of March. However, I did not take any risk for my patients with PSM between end of March to beginning of May. This week I have started to see the patients in out-patient clinic and I am following up in the ward.”

Emel further stated, “Actually, I do not have anything interesting on my site – everything was in order.” We would have to disagree, as we found her story very interesting indeed!

■ United Kingdom (Faheez Mohamed)

“We stopped elective operating in the last week of March 2020 as the need to protect ICU capacity in our hospital became clear. At that point we were performing an average of 5 to 8 peritoneal malignancy cases a week. We started elective operating again last week with a backlog of 90 cases to clear. This is being performed in our local private hospital whose capacity has been purchased by the NHS until the end of June 2020. We have continued to undertake telephone or video consultations for patients although we have limited face to face consultations. On average we have added 4 patients per week to the operating list. Normally we receive approximately 25 new referrals per week which has dropped to around 15 per week for the last few weeks. Our own ward in the NHS hospital was one of the first to be used for isolation of COVID-19 positive patients and is likely to be one of the last to return to us. We currently have 20 COVID -patients in our hospital from a peak of 100 3 weeks ago.

Routine diagnostics such as radiology and endoscopy have been suspended for the last month.

The Surgeons on our team have continued to provide emergency general surgery but have not served on the Coronavirus wards. Our surgical ward nurses and specialist nurses were redeployed and have provided frontline care. Unfortunately, as a result a number of our experienced surgical nurses have resigned. Of 5 surgeons who perform cytoreductive surgery for PMP I was the only one who tested positive for Coronavirus but thankfully I’m almost fully recovered.

Patients have been understandably anxious and frightened. Our 3 Specialist Nurses returned to their primary roles last week which has helped support patients who were listed for surgery before the pandemic broke and who are now waiting for new date for surgery.

Faheez notes, quite rightly, that “Telephone consultations are not ideal for new patients.”

“Numbers of new COVID19 cases appear to be falling and plans are underway to restart diagnostics and elective operating. A prioritisation panel in the hospital is deciding the order of cases to be performed based on a Priority level with cancer cases going first. We will need to do between 8 and 10 cytoreductive surgeries per week to catch up. There is a mountain of work ahead. The oncological impact of this delay is unclear but we are swabbing all patients pre operatively for COVID and re-scanning them including chest CT to protect patients and the team. We may also get some data on progression and impact on outcomes from this.”

We thank everyone who took the time to send in their experiences, and we hope that everyone else found this informative and interesting!