Posted 13 May 2021 - 09:00
Posted 13 May 2021 - 09:00
Analysis
How will cancer services and nurses have to adapt as we leave lockdown?
As COVID-19 restrictions ease there will be implications for cancer nurses and their patients
As COVID-19 restrictions ease what will be the implications for cancer nurses and the patients they care for?
- Following a drop in referrals during the pandemic, there is a drive to find ‘missing patients’
- There is evidence that COVID-19 vaccinations have less effect on people with cancer
- In-person care has resumed in some areas, but remote consultations continue and have to adapt
People’s freedoms are returning as COVID-19 lockdowns lift across the UK, but what are the implications for cancer nurses and the patients they care for?
From the way hospitals deliver care to a renewed drive to find ‘missing patients’ following a drop in referrals during the pandemic, the easing of restrictions provides some opportunities for nurses and patients to do things differently. But there are still significant challenges and risks to be faced.
Hospitals have undergone significant reconfiguring during the pandemic to create COVID-19-secure ways of working. This has involved regular testing of patients and staff, the creation of different zones – often referred to as red, amber and green – tight rules on visitors and a move to remote consultations.
Easing visiting restrictions on cancer and haematology wards will take more time
UK Oncology Nursing Society president-elect Mark Foulkes says that even though there are signs of restrictions easing in other parts of hospitals, cancer care will have to take it more slowly.
‘Cancer patients are at higher risk of complications – particularly haematology patients – and there is some evidence the vaccines have less effect. So while we are seeing visiting restrictions eased on general wards, for example, it will take more time on cancer and haematology wards.’
The ‘cool-down’ areas that are used for admissions to cancer wards so patients can be tested for COVID-19 will also be here to stay for a while, he says. ‘We would all appreciate some guidance on this, though. Cancer staff are having to work it out – and we are seeing tensions arise with patients asking why there are still restrictions.’
‘Nursing is hands-on by its nature – you lose something by only doing virtual appointments’
Mark Foulkes, president-elect of the UK Oncology Nursing Society
Mr Foulkes believes there could be some movement on virtual appointments and consultations. ‘The virtual approach is largely untested. It doesn’t work for everyone or in all situations. Nursing is hands-on by its nature – you do lose something by only doing virtual appointments. For post-treatment assessments, especially, it’s a problem, whereas for routine follow-up it’s less so.’
He also cautions against falling into the trap of assuming everyone has or is comfortable with using digital technology. ‘We’re going to need a mixed approach going forward.’
COVID-19 and vaccinations: what cancer nurses need to know
People with cancer can be at higher risk of complications from COVID-19, because the disease and its treatment can weaken the immune system
After treatment for cancer the immune system usually recovers over time. Having a vaccine with a weakened immune system may cause the body not to have as full an immune response as other individuals
COVID-19 vaccines have not been tested on people receiving cancer treatment, but specialists agree they are safe for most. There is no need for treatment to be delayed because of the vaccine
People with low platelets, bleeding disorders and low levels of white blood cells are, however, being told to discuss vaccination with their health team
People with cancer will fall into different priority groups depending on the nature of their condition – some have been entitled to it early, others have had to wait until their age band is called
Interim results from a study sponsored by King’s College London and Guy’s and St Thomas’ NHS Foundation Trust, which is looking at the impact of the Pfizer-BioNTech vaccination in patients with cancer, show that those with both solid and blood cancers were less likely to have developed antibodies after three weeks than people without cancer. A booster after three weeks significantly boosted antibodies for those with solid cancers
Source: Cancer Research UK
National Lead Cancer Nurses Forum member Alison Keen agrees. She says where remote consultations continue to be used nurses need to make sure they work as well as they can for patients.
‘We need to focus on making sure patients are fully involved in decision-making about their care – we had been making a lot of progress on that before the pandemic, but there is a risk with digital appointments that some of that is lost if we are not careful.’
Ms Keen says preparations for such consultations need to be carried out in a different way, so practitioners are ‘more aware of the patient’s story’. ‘Traditionally we would pull it up on the computer while we are talking to them. A relative may be in the room with them, contributing and helping. That dynamic is lost a little when done remotely.’
Questions that patients are encouraged to ask
She says The Health Foundation’s Ask Three Questions approach is vital. The technique encourages patients to ask the following:
• What are my options?
• What are the pros and cons of each?
• What support is available to help me make a decision?
50,000
Estimated number of missing cancer diagnoses across the UK by October 2020 predominantly due to the COVID-19 pandemic
Source: Macmillan Cancer Support (2020)
Ms Keen says: ‘If patients are asking these questions it will go some way to ensuring they have the information that’s important to them.’
Palliative nurses have been unable to provide as much support in the home as before
Community care shows more signs of change, with reports of complementary therapies, health and well-being sessions and drop-in support centres restarting in-person. Ms Keen says there is more scope for face-to-face care returning in community settings than there is in hospital, particularly for aftercare and recovery services.
She also hopes there will be more palliative care delivered in-person. ‘We know palliative nurses have not been able to provide as much support in the home as they used to. It has been a significant struggle for families. But again, there are signs it is changing.’
Macmillan Cancer Support treatment and medicines adviser Dany Bell, a registered nurse, says even in the opening weeks of easing restrictions there are signs of more face-to-face work taking place.
It’s hard not being in the room to provide support and empathy
But she says this is more a result of patient choice; in-person support was always available but some patients and their families chose not to have nurses in their homes because of the risk of COVID-19.
While regular phone and video support worked well for some, it was a challenge, she says. ‘Having difficult conversations about things like diagnoses, prognosis and end of life without being in the room with the person to provide support and empathy is hard.’
It is well-documented that in the first few months of the pandemic fewer people came forward with symptoms. There were multiple factors behind this, with research suggesting people were afraid of catching COVID-19, did not want to burden the health service, and because screening services stopped.
This caused a drop in referrals and treatment – by last October, Macmillan Cancer Support estimated there were around 50,000 missing diagnoses across the UK.
Since then the overall numbers have started returning to pre-pandemic levels, but this masks the differences between different types of cancers, with reports of lung cancer and prostate cancer referrals still being below what would be expected. There are also anecdotal reports that cancers are being diagnosed at a more advanced stage.
UK nations have already started responding.
The Scottish Government’s cancer action plan published in December made increasing referrals, particularly for lung cancer, a key priority.
In England, a recovery plan was also published at the end of 2020, with a public campaign called Help Us Help You urging people to come forward for non-COVID-19 issues. There has been a particular focus on cancer.
Meanwhile, Wales and Northern Ireland are promising to set out their own plans soon.
‘I support the idea of increasing cancer awareness campaigns and to remind people to seek medical opinion early. Cancer outcomes are better if they are treated at an early stage’
Mary Tanay, member of the European Oncology Nursing Society communications group
European Oncology Nursing Society communications group member Mary Tanay, who teaches at King’s College London, says such moves are welcome. She believes there is a significant challenge in tackling this, given the way ‘help-seeking behaviour’ has shifted during the pandemic.
People with cancer can be at higher risk of complications from COVID-19
‘Individuals are more aware of COVID-19 symptoms as a result of constant and consistent reminders and nudges by the government for more than a year. Cancer signs and symptoms are non-specific. Even prior to the pandemic, this presented challenges.
‘This is now compounded by the priority given to COVID-19. I support the idea of increasing cancer awareness campaigns and to remind people to seek medical opinion early. Cancer outcomes are better if they are treated at an early stage.’
People with cancer can be at higher risk of complications from COVID-19, and many will have been taking extra precautions during the pandemic. Some, including those receiving chemotherapy or immunotherapy and blood and bone marrow cancer patients, have been classed as extremely vulnerable and will have been on the official shielding list.
But with shielding now over in all parts of the UK, is it time for people with cancer to make the most of the easing of restrictions?
‘Cancer does not just affect you physically, there is a mental and emotional side to it’
Nikki Morris, RCN Cancer and Breast Care Forum chair
RCN Cancer and Breast Care Forum chair Nikki Morris says: ‘As restrictions lift, people understandably will want to see friends and family. It’s a quality of life thing – especially those who are palliative.
Being outdoors reduces any risks significantly
‘They are hard decisions to make. It will very much depend on personal circumstances. As nurses, it is our job to support them. We should be well informed of the risks so we can help them be informed.
‘What is key is listening and supporting them in their decision-making and stress they can always change their mind.’
She says one important message to stress is how being outdoors reduces any risks significantly. ‘We must remember that cancer does not just affect you physically, there is a mental and emotional side to it. Seeing people is important – not just family and friends, but others going through cancer too.
‘People make close bonds with others who have the disease – that is much harder over Zoom. Because of this we need to think about the psychosocial support patients are getting. Not only have they got cancer, they’ve had it in a pandemic – that brings extra challenges.’
Shielding during the pandemic left me isolated and anxious
Diagnosed with splenic marginal zone lymphoma, Malita Kilgour was finishing her chemotherapy treatment when the COVID-19 pandemic hit.
Her immune system was compromised as she has also had her spleen removed. ‘I’ve been shielding throughout,’ says Ms Kilgour from Dundee.
‘Its been incredibly hard not seeing family and friends. I live on my own so I have felt isolated and anxious at times. But you have to keep going.
‘I walk early in the mornings when no one is around and I have had regular contact with my cancer team, which has helped. The chemotherapy treatment had worked, so that stopped as the pandemic started. But my condition is chronic – it can be treated but it can’t be cured.’
A key source of support for people with cancer has been a mindfulness group organised by the charity Maggie’s, which has been run via Zoom during the pandemic.
‘It has been a lifesaver, but it’s not the same as meeting in person. To feel someone’s touch and to hold their hand when they are upset is something that cannot be replaced. I am about to get my second dose of the vaccine and I feel I have to start living my life again – I don’t know how long I’ve got.
‘I will always have to live with the risk of COVID-19 because of my compromised immune system, so I will be meeting up with people outdoors. I know if I get the virus there is a real risk it will kill me. But I can’t keep living like I have over the past year.’
Find out more