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\begin{document}

\title{Virtual Gynaeoncology Clinics: Are they an effective way to keep the
cancer pathway working in the COVID-19 era? A Commentary}



\author[1]{Thumuluru Kavitha Madhuri}%
\author[2]{Alex Tan}%
\affil[1]{Royal Surrey County Hospital NHS Foundation Trust}%
\affil[2]{Royal Surrey NHS Foundation Trust}%


\vspace{-1em}



  
  \date{May 21, 2024}


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\begin{abstract}
The COVID-19 pandemic has presented the NHS with unprecedented
challenges following the declaration of ``global pandemic'' by the
WHO.\textsuperscript{1} In response to this crisis, reconfiguration of
services and resource allocation were undertaken across all levels with
a view to provide effective supportive and emergency care as well as
minimise risk of exposure to the infection in
hospitals.\textsuperscript{1}%
\end{abstract}%



\sloppy


The COVID-19 pandemic has presented the NHS with unprecedented
challenges following the declaration of ``global pandemic'' by the
WHO.\textsuperscript{1} In response to this crisis, reconfiguration of
services and resource allocation were undertaken across all levels with
a view to provide effective supportive and emergency care as well as
minimise risk of exposure to the infection in
hospitals.\textsuperscript{1}

As an immediate adaptation, the NHS reduced face-to-face outpatient
consultations and postponed non-urgent
appointments.\textsuperscript{2,3} This was believed to be a pragmatic
approach in reducing footfall into hospitals and primary care providers
which, in turn, would reduce viral transmission in the outpatient
setting.\textsuperscript{2,3}

The cost of this transient process has been significant to stakeholders
and while the true impact of this reaction is yet to be fully revealed,
patients requiring key investigations and treatment in secondary care
have been hesitant to seek help for two common
reasons.\textsuperscript{4,5} This was mainly due to patients not
wanting to be a burden on healthcare providers during this crisis,
drawing them away from sick patients and the ongoing fear and anxiety of
contracting the viral infection within the
hospital.\textsuperscript{4,5}

The NHS quarterly results (Q2 2019/2020) reported that the number of
women seen with a suspected gynaecological malignancy within the
two-week wait and diagnosed (31-day target) ranges widely across the UK
regions.\textsuperscript{6} Rapid adoption of telehealth and
telemedicine allowed the NHS to explore and employ virtual modes of
consultations.\textsuperscript{7} These virtual clinics would typically
involve a video conference or telephone consultation between the
healthcare professional and patient on registered contact details to
discuss various aspects of their care, ranging from triaging reported
symptoms, alleviating anxiety to facilitating key investigations and
expediting management plans. \textsuperscript{5,7}

As early adopters of the virtual clinic model in gynaecological
oncology, we would encourage all departments to allocate designated time
to assess new cancer referrals as well as follow up patients under
surveillance and effectively screen for individuals most likely to
benefit from this approach rather than deferring or cancelling
appointments as the initial response. Where feasible and with patient
consent, they are booked in for a virtual consultation using existing
trust models of secure electronic communication and contacted with clear
instructions via text, email or post depending on local trust policy.

Digitisation of patient records through electronic patient records (EPR)
remains key to enable NHS delivery of such virtual
clinics.\textsuperscript{8.9} In light of the increased use of various
commercial platforms including Zoom and Microsoft Teams for both
clinical and managerial activities, safer data encrypted platforms such
as NHS attend anywhere platform should be advocated for all NHS
healthcare professionals in order to be compliant with the Data
Protection Act and Patient Confidentiality.\textsuperscript{10}

All virtual consultations should be ideally recorded and clearly
documented in case notes. An audit trail of written correspondence
between the secondary care professionals, primary care providers and
patients should be regularly maintained in the similar manner as
conventional face-to-face consultations in order to maintain continuity
of care.

Despite playing a major role across most specialties in this crisis, we
do not feel that virtual clinics are superior to face-to-face
consultations as the gold standard of care. Certain individuals with a
high index of suspicion of malignancy are still encouraged to attend
hospital appointments for a timely diagnosis and early treatment. We
also need to seriously consider the ethical implications and moral
dilemmas of discussing new diagnoses, complex treatment regimens and
cancer follow-ups virtually, especially in vulnerable patients. However,
we acknowledge the acceptability of this modified approach based on
various patient satisfaction surveys and its future role in advocating
patient-initiated follow up services in selected groups of
individuals.\textsuperscript{11}

Despite facing numerous limitations in the delivery of our cancer care,
an opportunity for change has presented itself and the gynaecological
oncology and other allied health professional teams could embrace this
challenge as a cohesive team and actively implement targeted virtual
clinics to advocate timely diagnosis and expedite treatment.

\textbf{Disclosure of interests:} Both authors confirm that they have no
interests to declare

\textbf{Contribution to authorship:} TKM conceived the idea and both TKM
and AT contributed to the manuscript preparation. Both authors have read
and approved the final draft submitted.

\textbf{Ethics Approval: Not required}

\textbf{Funding: none}

Pandemics pose a challenge to all involved in the delivery of
healthcare; however, using a targeted virtual clinic approach will keep
the pathway moving for patients with high-risk urological malignancies
and enable us to resume services in a much-improved position NHS
England. NHS Statistics on Waiting Times for Suspected and Diagnosed
Cancer Patients Q2 2019/20. NHS Englan

\textbf{References}

\begin{enumerate}
\tightlist
\item
  WHO Coronavirus Disease (COVID-19) Dashboard. \emph{World Health
  Organization.} Webpage. Available from https://covid19.who.int/
  {[}Accessed 24\textsuperscript{th} June 2020{]}
\item
  NHS long term plan. \emph{NHS.} Webpage. Available from
  https://www.longtermplan.nhs.uk/ {[}Accessed 24th June 2020{]}
\item
  Van de Haar J, Hoes LR, Coles CE, et al. Caring for patients with
  cancer in the COVID-19 era. \emph{Nat Med} 2020 May; 26(5):665-671.
  Doi: 10.1038/s41591-020-0874-8. Epub 2020 Apr 16.
\item
  Coronavirus and the impact on output in the UK economy: April
  2020.\emph{Office for National Statistics.} Webpage. Available from
  https://www.ons.gov.uk/economy/grossdomesticproductgdp/articles/coronavirusandtheimpactonoutputintheukeconomy/april2020
  {[}Accessed 24\textsuperscript{th} June 2020{]}
\item
  Rodler S, Apfelbeck M, Schulz GB, et al. Telehealth in Uro-Oncology
  beyond the pandemic: Toll or Lifesaver? \emph{Eur Urol Focus.} 2020
  Jun 10;S2405-4569(20)30145-0. Doi:10.1016/j.euf.2020.05.010.
\item
  Quarterly Provider Based Cancer Waiting Time Statistics.
  \emph{NHS.}Webpage. Available from
  https://www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times/quarterly-prov-cwt/
  {[}Accessed 24\textsuperscript{th} June 2020{]}
\item
  Al-Shamsi HO, Alhazzani W, Alhuraiji A, et al. A practical approach to
  the management of cancer patients during the noval coronavirus disease
  2019 (COVID-19) pandemic: An international collaborative
  group.\emph{Oncologist.} 2020 Jun;25(6):e936-945. Doi:
  10.1634/theoncologist.2020-0213. Epub 2020 Apr 27.
\item
  Hollander JE, Carr BG. Virtually Perfect? Telemedicine for
  COVID-19.\emph{N Engl J Med.} 2020 Apr 30;382(18):1679-1681. Doi:
  10.1056/NEJMp2003539. Epub 2020 Mar 11.
\item
  Hollins L-Transforming outpatient care. \emph{NHS.} Weblog. Available
  from https://www.england.nhs.uk/blog/transforming-outpatient-care/
  {[}Accessed 24\textsuperscript{th} June 2020{]}
\item
  What is Attend Anywhere/Near Me?. \emph{NHS Scotland.} Webpage,
  Available from https://www.vc.scot.nhs.uk/attendanywhere/ {[}Accessed
  24\textsuperscript{th} June 2020{]}
\item
  Newton C, Nordin A, Rolland P, et al. British Gynaecological Cancer
  Society Recommendations and Guidance on Patient-Initiated Follow-Up
  (PIFU). \emph{Int J Gynecol Cancer.} 2020 May; 30(5):695-700. Doi:
  10.1136/ijgc-2019-001176.Epub Apr 19.
\end{enumerate}

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