U.S. oncologists can learn from low- and middle-income countries how to triage care for cancer patients with limited resources throughout the COVID-19 pandemic.

Cancer care with limited resources: Six lessons from low-income countries

September 16, 2020
by John R. Fischer, Senior Reporter
From choosing which procedures to delay to rationing PPE and other resources, the COVID-19 pandemic has forced clinicians and administrators to reevaluate, long-term, how they will deliver care to cancer patients.

Researchers at the University of California, San Francisco are looking to low- and middle-income countries like Rwanda and Tanzania for insight on how to balance limited resources against patients in urgent need of care.

“Although the need to triage cancer care may be new to those who underwent training and now practice oncology in high-resource settings, it is familiar for those who practice in low- and middle-income countries,” wrote the authors. “Oncologists in the United States facing unprecedented decisions about prioritization can draw on ethical frameworks and lessons learned from real-world cancer care priority settings in resource-constrained environments.”

Here are a few of those lessons:

A utilitarian approach
Overall survival is the universally accepted standard measure of clinical benefit in oncology, and in areas with limited resources, a utilitarian approach maximizes survival benefit and should guide decision-making, according to the authors. This means prioritizing curative over palliative treatment, long-term over short-term disease control, and higher magnitudes of benefit. Decisions should be based on objective estimates such as an intervention’s cure rates or disease-free survival, as well as factors such as a patient’s age, performance status and comorbidities. Tools such as work developing prioritization guidelines for limited radiotherapy resources have helped Rwanda make decisions based on estimated incremental curative benefit by cancer type and stage.

Settling conflicting principles
Different stakeholders have different principles that can clash. Motivations include moral and ethical obligations to patients, respect for human dignity, and a legal duty to act in the patients’ best interests. In Rwanda, oncology clinicians recognize that it is difficult to not be able to send a patient for palliative radiotherapy but still prioritize those who have a chance of being cured over those that do not. They also agree that life expectancy and potential life-years gained by curing disease should be accounted for in the allocation of limited radiotherapy resources. One way to make decisions based on morally relevant considerations is through a multi-principle allocation system such as priority scores for ventilator allocation.

Setting up fair decision-making procedures
A procedural approach for setting priorities can settle disputes or situations where there is no consensus on which normative principles should guide healthcare rationing and resource allocation. One example is the Accountability for Reasonableness framework, which requires decisions and rationales to be transparent to the public; relevant to stakeholders including patients; and revisable under a regulated process.

Implementing proactive safeguards
Proactive safeguards protect low-income and marginalized communities that are at particularly high risk. Rwanda and Tanzania have each teamed up with partners to fully cover or subsidize out-of-pocket costs of cancer treatment for low-income individuals. Through these efforts, they have provided social support for food and transportation, patient navigation systems, and mobile health technology strategies that reduce treatment abandonment. Other potential safeguards could include expanding access to internet and devices for telemedicine, strengthening outreach and tracking systems for vulnerable patients, and increasing social work and supportive care services.

Communicating with patients and families
High-quality communication between patients and clinicians reduces anxiety and depression and is critical during the pandemic. Standardization across clinicians, skills training, and transparent objective criteria have helped providers in Rwanda and Tanzania have difficult discussions about resource limitations and prioritization decisions with patients.

Avoiding burnout
As oncologists in high-income communities are used to providing the highest standard of care, they are likely to feel morally conflicted in having to limit care during the pandemic. Interventions such as individual-level coping and resilience programs and organization-level changes can help them address moral distress and in effect, reduce risk of burnout among clinicians. Activities that build community and camaraderie among interprofessional oncology clinicians also help in this effort.

“A prolonged period of macroeconomic effects, such as unemployment and reduced public sector healthcare expenditures, may lead to excess cancer-related deaths on a large scale,” wrote the authors. “As oncology practices adapt to a contracted health care system, using principled approaches and the wealth of experiences in oncology resource prioritization from LMICs may help guide decisions and implementation.”

Employing principled guidelines, fair deliberative procedures, safeguards for vulnerable patients and standardized communication tactics have helped LMICs navigate the challenges of the pandemic and can also do the same for high-income countries like the United States, assert the authors.

The findings were published in JAMA Oncology.