Cancer Treatments Must Continue Regardless of COVID-19By Jan Hogewoning | Tue, 07/21/2020 - 13:45
Q: How has the pandemic impacted interinstitutional collaboration to advance the government’s health agenda?
A: The health sector has seen a great deal of change in recent years. We have a new government and a new approach to health administration that is attempting to unite the fragmented system of the past. The old health system decided whether someone had access to healthcare on the basis of their economic situation or work status. The new government has started to work on the universalization of healthcare, homologating different systems. As a result, the new Health Institute for Well-Being (INSABI) was created. SMEO has been participating in this process indirectly with the final objective of providing accessible and free healthcare to anyone, regardless of their background. In 2020, we were in talks on how to move this forward, but then the pandemic hit. This has changed the primary priorities of health authorities and has also relegated cancer and other diseases to second place behind the virus.
Q: How has the pandemic impacted cancer treatment services in the country?
A: People with cancer are at high risk with COVID-19, not just because of the cancer itself but also because of the condition of their immunosuppression. In addition, many cancers are associated with other major pandemics in this country, including obesity and metabolic syndrome, which in turn are linked to hypertension and cardiovascular disease. Together, they form a dangerous mix for the COVID-19 outbreak.
Our cancer patients have been affected in three ways. Firstly, in terms of care, both in the public and private sectors, we have had to reassess priorities. We have had to find a way to treat cancer, which cannot wait, and protect patients against COVID-19. We have had to prioritize patients at the National Institute of Cancerology according to their diagnosis, addressing the challenges this involves. In many cases, we could not halt treatment and we used all precautions, including isolation, to continue the cancer treatment. Our expectation is the pandemic in Mexico will soon slow down, giving us the chance to go back to all patients and resume treatments.
The second way in which patients have been affected is through the reconversion of hospitals into COVID-19 clinics. This has led to displacements of patients to other centers. In Mexico City, patients were moved out of Hospital Juárez, Hospital General de México, the National Institute of Nutrition and the National Institute for Respiratory Diseases. The National Institute for Cancerology had to offer cancer treatment to many of these patients. A similar process of displacement took place in other large cities like Guadalajara and Monterrey. However, in many other hospitals around the country, assistance for cancer patients was postponed as the option of moving them to other COVID-19-free hospitals did not exist. The result is that people were not diagnosed and assisted at an early stage, which means they will have more advanced cancers by the time they are treated. Mexico’s cancer-related deaths currently stand at 85,000 a year.
The third impact has been on research. The pandemic has shifted CONACYT’s focus from cancer, as well as resources, to COVID-19. The council is looking into the impact of COVID-19 on subgroups, such as cardiac patients, children and pregnant women. In SMEO, through Cooperative Groups of Research, we have a national plan in which 103 researchers at 143 centers of IMSS, ISSSTE, federal and state health institutions are reporting on the impact of COVID-19 on cancer patients. This will help us understand the risk and allow us to adjust our steps.
Q: How is the pandemic affecting oncology education and training?
A: From the teaching perspective, courses for specialization, which are dependent on support from the Ministry of Health and UNAM, have been affected because physical classes have become impossible. SMEO has worked to migrate to virtual medical education. As a result, attendance has actually doubled from a normal rate of 150-200 students. Online channels have allowed us to continue to share the latest oncological developments at the national and international level.
Q: What lessons have you learned that could help SMEO move forward?
A: We participated in a forum organized by The Society of Surgical Oncology, called the Global Forum for Cancer Surgeons. We were able to hear doctors in Spain and Italy sharing their experiences on COVID-19. These two countries reconverted all their hospitals. What they found was that this had a very negative impact on oncological attention for patients. The number of patients arriving with advanced tumors doubled in three months. Here in Mexico, we have been able to keep hospitals and oncological centers free of COVID-19, without having to reconvert them 100 percent. This maintained a respectable level of attention for cancer patients but we still need to see what the full impact of the virus will be.
Going forward, we need to keep insisting on providing oncological treatment, including follow-up treatment. This is as important as taking COVID-19 precautions. From a public policy point of view, patients should continue to have access to cancer treatment regardless of the COVID-19 situation. We are working to provide other tools for continuing treatment, such as telemedicine and telephone consults. Patients can receive follow-ups and any doubts can be answered. These tools used to be just a plus but now digital access is essential. Obviously, in Mexico, not everyone has an internet connection. We estimate that at least about 30 to 40 percent of the oncological population cannot access this opportunity. In this case, it is vital to work on local and state level strategies to continue to reach people.
Q: Regarding the government’s plan to create a more universal health system, what have been the main challenges in this area?
A: There are many challenges. There is a need to harmonize the different perspectives of players in the sector to overcome these challenges. The system is still too fragmented. The government, civil societies like SMEO, pharmaceutical companies and medical distributors should join forces by focusing on one objective: better care for the patient regardless of background. I hope that by the end of this or next year we can return to this agenda, which will also be boosted by the social commitment of pharmaceutical companies.
I’m convinced that universal healthcare should not be limited to oncological drugs. The treatment of cancer is multidisciplinary, combining chemotherapy with surgery and radiotherapy. To limit access to just medication, you are dealing with only a third of the problem. All cancer treatment centers should be drawn into one vision. In the area of surgery, we need to ensure that anyone can have access to surgery performed by oncological specialists with the right experience. This harmonized approach is what the government and SMEO are moving toward.
One challenge for the government is to determine the most suitable strategy to consolidate direct medication purchases to avoid overpriced goods. There are government commissions working together with the Ministry of Health to find the best treatments according to cost and effectiveness. There are many cancer treatments that are very expensive and that have a marginal benefit or a very selective impact on patients. The option to provide surgery as local treatment in early and selected cases, is also considered.
Q: Why has it been impossible to ensure universal access to cancer treatment in the past?
A: The Fund for Protection against Catastrophic Expenses of the National Health Protection System (FPGC) is the financing for the care of SPSS beneficiaries suffering from high-cost illnesses, those that cause catastrophic expenses, administered by a trust, was created in 2003. This was called Seguro Popular.
By 2008, the government final wanted to complete universalization, moving to include all cancers gradually. At the end of the program, all the cancer in children, and 48 percent of cancer morbidity and 40 percent cancer mortality, was covered, with crucial differences between systems (IMSS, ISSSTE and Seguro Popular). Most of the problems was presented at state level, which led to resources that were destinated to cancer no ending up where they should. Then the previous government decided to merge this fragmented landscape into one system, but failed.
What we are aiming for is something similar to what the UK has, where you have one system compartmentalized per region. In this system, it does not matter whether you are employed by the private sector, the government or the informal sector because everyone has access to the same treatments and same medications. The current systems benefit private sector employees receiving care under IMSS, creating an unacceptable and inequity.
Ultimately, the management of healthcare is embedded in the Constitution. What can change through new administrations can be secondary regulations and policies. This is why it is so important to create a unified vision between different parties across sectors.
Q: What would you consider your primary priorities for 2020?
A: We are dealing with a global health and an economic crisis. They are intrinsically linked. Our goal is to get patients back to health in the best way we can. Secondly, we are working hard to integrate the virtual chain of health care, education, and research for patients, students and oncologist.
The Mexican Society of Oncology (SMEO) aims to stimulate research and education in the field of cancer treatment. The society works together with the government and private entities to achieve this goal