Running a breast department and providing breast cancer services at any given time is a challenge but when the COVID-19 pandemic settled in, the load of challenges drastically increased. Dr Jenny Edge gives us a summary of how the Tygerberg Hospital (TBH) Breast and Endocrine Clinic handled it and the advances it has brought.
We can’t translate what happens in a high-income country with what happens in this country. This is not only for breast cancer services but also in the way that we’ve had to handle the COVID pandemic. We spend a lot of time trying to decide what is fair and reasonable for our patients with the resources that we have.
COVID first wave limitations
In comparison with other African countries, SA’s COVID-19 case count is high, and the third wave is here. A lot of limitations were imposed with the first wave. We had to decrease the clinic visits by 30% with immediate effect; decrease support services available, such as phlebotomy or biopsies, being done. Ultimately, it meant that we had to increase the work we did in the clinic while at the same time decreasing the clinic visits for patients.
Overnight, there was no face-to-face teaching allowed and we had a few weeks to convert all face-to-face teaching to online content. Our theatre time was decreased by half. We also had to ensure that our post-operative patients only remained in hospital for a minimal time. Access for palliative care patients into the system was problematic. Our palliative care patients were often mixed with COVID patients (as their symptoms were often very similar) which caused barriers to their access to care.
Breast cancer in SA
In 2019, roughly 50% of our population had Stage 3 or 4 breast cancer at the time of diagnosis. Patients in the public sector follow a timeline from when they first present at a primary healthcare facility through to the initiation of treatment. According to the National Breast Health Policy, this should be over a span of no more than 60 days which is a huge challenge in normal times and with the pandemic, became even more of a challenge.
We don’t have final figures from 2020. This year, we are seeing many patients returning to our service having not been able to adhere to their treatment plan. Subjectively, it’s my impression that new patients are being diagnosed at a later stage.
Clinical breast examination, as a means of screening, is often criticised. However, in a resource limited environment, it has shown to be a helpful tool. Currently, we run two courses for healthcare provider training. The Breast Care Course is a higher-level education course for registered nurses through Stellenbosch University. The Breast Course for Nurses is a course for all types of healthcare workers and is aimed at equipping the healthcare worker with the basic skills to assess patients with breast problems.
In 2020, we were unable to run any breast course training, but the National Department of Health approached us to team up as they were creating an online course available for all primary healthcare nurses. We contributed the modules pertaining to general oncological principles and the breast cancer specific modules.
New ways of communication
The Breast and Endocrine Clinic at TBH deals with not only breast problem-related patients but also endocrine, melanoma, salivary gland and soft tissue tumours.
During the initial lockdown, we created a website for the clinic. This site is a means for doctors to know who to refer and how to refer. It’s also a means to introduce the team at the clinic. COVID has allowed us to all get to know each other very well within the clinic. This includes the four pillars: cleaning services, administration, nursing and medical.
Telephone clinics were introduced. The clinic was spilt in two parts; half would see patients, half would be doing the telephone clinic. The clinic sisters would call the patients to ensure availability and to give them a timeslot for the doctor to call them.
New patients would be called before they arrived so that all appropriate investigations could be booked in advance, and all follow-up patients were called to see if they needed to be seen in person or not. We had internet installed within the clinic so that we could make use of internet calls as a means of a more efficient and less costly service. Knowing that data and telephone costs can be very expensive, we also started a WhatsApp line for patients to use to contact us.
About 40 patients are discussed at our weekly multi-disciplinary team (MDT) meeting. Although the patient isn’t present at the MDT, they remain the centre of the decision-making process. Our MDT had to become a virtual meeting, and this has had a number of advantages. It has allowed the peripheral hospitals to participate in the meeting and the decision-making process. It has also encouraged communication between the tertiary and secondary hospitals.
New study to decrease seroma formation
We had to also reduce subsequent post-operative visits to the hospital for our patients. We commenced a study to look at the use of fixation post-mastectomy with a fibrin sealant to decrease seroma formation as this is a major post-operative side effect that we see in patients. The patient’s hospital stay is often increased due to seroma drainage and, in most cases, patients do have to go home with drains and need to return to the hospital to have it removed.
The seroma formation is largely due to the stage of the patient’s breast cancer and BMI of the patient. Eighty percent of our patients have a high BMI and most present with locally advanced breast cancer. By reducing seroma formation, we can reduce the use of drains, especially for longer periods of time, and patients wouldn’t need to return to hospital to have them removed therefore decreasing the post-operative visits. For those patients that do, however, need to go home with drains, they are phoned daily and may return at any point if concerned.
The upside that COVID has given
We could focus on what we have been missing (accessibility to the clinic for patients, conversations with our patients, support groups, communication with relatives, predictable theatre lists, and the list goes on), but instead, let us focus on all the positives.
We have built a great sense of community; buddy checks and a WhatsApp group for the clinic members have been developed which we have never had before. COVID has given us a way to fast-track implementation of changes in the clinic, such as electronic notes and telephonic clinics. Implementation of changes was previously a very slow process. Communication channels have improved with not only patients but other team members and other hospitals. This has made the biggest difference to the service we can provide for our patients.
At the end of the day, our patients have remained our priority and will continue to be the centre of the decision-making process during the pandemic and into the future.
MEET THE EXPERT – Dr Jenny Edge
Dr Jenny Edge is head of the Breast and Endocrine Surgical Unit at Tygerberg Hospital. She is the founder of the Breast Course for Nurses.
Header image by Freepik