By the time Pedro Gomez Marin met the surgeon who would remove his oral cancer and rebuild his jaw, the tumour in his neck was nearly as big as a golf ball.
The mass had ballooned since Mr. Gomez Marin, a retired owner of a landscaping and snow removal business, first noticed a bump that felt like a small nut three months earlier. The 71-year-old, who goes by Peter, needed major surgery right away.
“[The surgeon] told me that this type of cancer Peter has is quite an aggressive, fast-moving cancer. It has already spread into the bone in his jaw,” said Karen Leahy-Gomez, Peter’s wife of nearly 40 years.
“So to me, it was very important that he get that surgery done as soon as possible. But the doctor told me right off the bat that because of COVID – because apparently the ICU rooms and the operating rooms are more busy than usual – it could take longer.”
Thirty-seven days elapsed between the day Mr. Gomez Marin was officially added to the surgical queue at Toronto’s Sunnybrook Health Sciences Centre and his operation on March 3 – nine days longer than the maximum cancer patients are supposed to wait for the type of surgery he required.
Antoine Eskander, the head and neck oncologist who spent 13 hours reconstructing Mr. Gomez Marin’s jaw with bone and tissue from his shoulder blade, said he worried not just about the time it took to book the surgery, but about the time it took for Mr. Gomez Marin to make it on to the waiting list in the first place.
Would the health care system have swept Mr. Gomez Marin’s case along faster in the before times, when a pandemic wasn’t pinching resources at every stop along the path to a cancer surgery?
“He may be a COVID victim,” Dr. Eskander said, “and he just doesn’t know it.”
That description could apply to nearly every Canadian who needed medical attention for something other than COVID-19 in the past 12 months, and it may continue to apply for years to come.
The pandemic’s impact on non-COVID-19 medical care is so far-reaching it’s nearly impossible to grasp. The physicians and researchers studying it are like the blind men in the fable, each of them toting up the damage done in their own specialties without the ability to see how wounded Canada’s beast of a health care system has become.
Dr. Eskander, for instance, knows how cancer care in Ontario – his part of the elephant – has been hurt. As an adjunct scientist at the non-profit Institute for Clinical Evaluative Sciences, he has been tracking data on screening tests, new diagnoses and oncology surgeries, all of which are down from prepandemic days.
There was an immediate 60-per-cent drop in Ontario’s cancer surgical volumes on March 15 of last year, when the provincial government ordered a halt to all but urgent and emergency surgeries, according to a recent study by Dr. Eskander and his colleagues. The volume increased by six per cent a week over the next three and a half months, but never fully recovered.
By the end of June, Ontario’s cancer surgeons had performed 35,671 fewer operations than in a similar period before the pandemic.
And that was one wave, in one province, in a category of care prioritized above most others because of the life-and-death consequences of delaying cancer surgery.
“The impact is going to be felt for years to come,” Dr. Eskander said of redirecting health care resources to fight COVID-19. “We’ve got a big problem – a problem we don’t even realize yet.”
To take a single example of an unexpected problem, consider stem-cell transplants.
The number of new recruits to Canada’s stem cell registry is down 70 per cent because mass cheek-swabbing events, often held on college and university campuses, have been cancelled.
Closed borders and scrapped flights have made importing fresh stem cells a challenge, according to Heidi Elmoazzen, stem cells director for Canadian Blood Services. That means patients with blood cancers and other diseases may have to settle for donor cells that are a less-than-ideal genetic match.
In a bid to quantify the more straightforward deficits in non-COVID-19 medical care, The Globe and Mail drew on public reports and surveyed provincial governments on changes in surgical activity, cancer screening, cancer diagnoses and emergency department visits during the first year of the pandemic.
There were reductions across the board, including in the Atlantic provinces and in parts of the health care system barely scathed by the virus itself, such as pediatrics.
Children’s operations, for example, fell by 44 per cent in Ontario, steeper than the 34-per-cent drop in adult non-oncology surgeries, according to data provided by Ontario Health – despite pediatric hospitals admitting comparatively few patients for COVID-19, a disease that’s mild on children and teens. (Those figures exclude transplants and heart surgeries.)
In an October commentary in the Canadian Medical Association Journal, the surgical chiefs of Canada’s major children’s hospitals estimated that 7,600 pediatric operations were postponed across the country between mid-March and late May or early June, depending on the province. Another 4,000 couldn’t even get on a waiting list.
When it comes to patients of all ages, the Canadian Institute for Health Information (CIHI) found that about 335,000 fewer surgeries happened in the spring of 2020 than in the one previous, a 47-per-cent reduction.
The drop wasn’t as precipitous during the fall and winter, even though the second wave was more punishing than the first by most measures. Hospitals tried to keep operating rooms running at high volumes, rather than cancelling elective surgeries pre-emptively as provincial governments, terrified by the images out of Wuhan and northern Italy, had ordered them to do at the start of the pandemic.
But in second-wave hot spots such as Edmonton, Winnipeg, Quebec City, Brampton, Mississauga and Toronto, hospitals were still forced to postpone tens of thousands of scheduled surgeries to free up staff and space for patients sickened by a virus that government policy and individual behaviour failed to control.
If a variant-fuelled third wave outruns Canada’s vaccination campaign as many epidemiologists fear, the backlog will grow. Ontario’s COVID-19 Science Table plans to publish a brief Monday showing that new variants of the coronavirus are significantly increasing the risk of hospital admission, ICU admission and death, and that hospital admissions for COVID-19 are now skewing younger.
The Ontario Hospital Association, meanwhile, warned on Friday that the province’s critical care system is approaching a “saturation point” that will test its ability to provide life-saving care to COVID-19 and non-COVID-19 patients alike, including those who need surgery.
Patients in surgical queues at least know what medical care they need. Doctors interviewed for this story were equally worried about Canadians stalked by heart disease, cancer and other illnesses that have gone undiagnosed in the past year.
In Quebec alone, researchers are bracing for thousands of excess cancer deaths in the next five years, each of them an individual whose cancer might have been successfully treated if not for pandemic-related delays in diagnostics and surgery.
Talia Malagon, a cancer epidemiologist at McGill University and a member of a McGill team studying the impact of the coronavirus on cancer care in the province, has designed a model that projects 8,094 excess cancer deaths between 2020 and 2025, the equivalent of a five-per-cent increase in cancer mortality in Quebec.
“If we do make efforts to absorb the backlog, it will likely be less than that,” she said. “Worst-case scenario, if we remain at current treatment capacity – pandemic-level treatment capacity – it will likely be much more than 10,000.”
In September of 2019, Norma Mariga underwent an operation on her left foot that relieved years of sharp pain caused by arthritis and a bunion, a bony bump in the joint at the base of her big toe. The 71-year-old retired supervisor with the Canada Revenue Agency was supposed to have the same operation on her right foot about six months later, likely in May of 2020.
Then the pandemic hit. The surgeon’s office, which had promised to contact Ms. Mariga with a date, never called.
Waiting nearly a year longer than recommended for her second surgery has left Ms. Mariga favouring her good foot. The pain, exacerbated by her uneven gait, has spread to her knees and hips. “It is still excruciating,” she said.
Despite that, Ms. Mariga hasn’t called to ask for a surgery date.
“Frankly, I would rather just wait until things are safe, with vaccinations and whatnot, before I start pushing to have this other foot done,” she said in a phone interview from her home in Lively, near Sudbury.
Fear of the coronavirus has prompted an untold number of Canadians to avoid operating rooms if they can. The same is true of doctors’ offices, many of which have pivoted to virtual care, and of emergency departments, where volumes have plummeted whenever COVID-19 cases have spiked in the community.
In the panicked early phase of the pandemic, emergency department visits dropped by about 50 per cent across Canada, according to CIHI. Patients began returning as the first wave ebbed, but in places where the second wave hit harder than the first, such as Manitoba, visits to emergency departments and urgent care centres fell by about one-third in November and December compared with the same months in 2019. Even New Brunswick, a province that kept the virus on a tight leash, saw ED visits in April to December of 2020 drop 25.7 per cent compared with the same period the year before.
Some of the reduction is evidence of a rare silver lining to the pandemic, as Alberta Health Services pointed out in explaining why visits to two dozen of its emergency departments had dropped by 24 per cent as of the end of January. Public-health measures crushed influenza and other run-of-the-mill winter viruses so thoroughly that emergency visits for pneumonia, chronic obstructive pulmonary disorder and gastroenteritis plunged.
The other side of the explanation is bleaker, according to Michael Hill, a stroke neurologist at Calgary Foothills Hospital.
“We’ve seen more deaths at home,” he said. “There are people who are essentially DOA – dead on arrival – because they’re waiting at home with their chest pain and not coming to hospital.”
Dr. Hill, who is also the stroke lead for the Cardiovascular Health and Stroke Strategic Clinical Network at Alberta Health Services, said he is seeing more patients with suspected strokes arrive at the hospital when they’re beyond help. “That’s sad, right? I mean, it’s tough. And of course, of the people that survived, I also had a lot of folks who were more severely disabled.”
Proof of this phenomenon is beginning to turn up in Statistics Canada’s reporting on excess deaths during the pandemic. The statistical agency recently pointed out that, in Ontario, 4,345 people died of heart disease in the spring of 2020, up 5 per cent from 4,125 in the spring of 2019 and higher than in any of the past five spring seasons.
Alberta Health Services is trying to counter patients’ fears with a public awareness campaign dubbed “Listen to your body.” The campaign expanded in February to include heart and stroke warning signs after launching as an effort to persuade people with possible cancer symptoms to get themselves checked out.
Figuring out how many “missing” cancer cases are percolating, untreated, in Canada right now is among the major concerns of oncologists.
In Alberta, the number of new invasive cancers diagnosed between March and December of 2020 was down 10 per cent from the same period in 2019, a difference of 1,682 cases. B.C. and Ontario peg their decreases at an estimated 20 and 25 per cent, respectively, in the first wave.
Other provinces, including Manitoba, Saskatchewan and Nova Scotia, say early indications are that new cancer diagnoses are roughly in keeping with past years.
The McGill team studying the issue is trying to tease out which of the many pandemic-related delays are most likely to contribute to higher cancer mortality down the road. Could it be the decision to shut down nearly all routine cancer screening during the first wave, including mammograms for breast cancer, fecal tests for colon cancer and pap smears for cervical cancer? What about longer wait times for diagnostic procedures, such as colonoscopies, or even minor delays in cancer surgery?
“As we opened more COVID wards, we had to close a lot of operating rooms. That’s a fairly widespread experience across the world,” said Wilson Miller, a professor of medicine and oncology at McGill and leader of the university’s task force on the impact of COVID-19 on cancer control and care.
“Even when we get the nurses back – when they’re not all burned out, when their kids don’t have quarantine – the process of surgery has slowed down because of increased procedures to make the operating room safe.”
The ripple effect of that reality is among the reasons patients such as Annie Lévesque have no idea how much longer they’ll have to wait for life-changing surgery.
Ms. Lévesque, a 42-year-old personal-insurance analyst living in Quebec City, grew up with spondyloepiphyseal dysplasia, a genetic condition that affects bone and cartilage growth. The mother of two used to enjoy nature hikes and downhill skiing, but those activities became impossible as her condition deteriorated in recent years, exacerbated by rheumatoid arthritis and particularly by osteoarthritis.
Her hips lock up several times a day, immobilizing her. Just before the pandemic started, she learned she would need arthroplasty procedures on both hip joints, and that the wait time would be one year to 18 months.
Now, with the pandemic, Ms. Lévesque has been told the surgery might not happen until 2024.
“I have an ever-present fatigue, which brings in other issues, psychological issues,” she said. “I have to pace myself to be able to live through the day as normally as possible.”
From the start of the pandemic, Quebec nephrologist Rita Suri and her fellow kidney specialists worried their patients would be among those most hurt by the crisis. Their fears were well-grounded: Dialysis patients are medically fragile, and their life-sustaining, three-times-per-week treatments can’t be postponed or delivered virtually.
As it turned out, one in 10 Quebec dialysis patients has been infected with COVID-19. Of those, approximately half were admitted to hospital and more than 20 per cent have died, according to preliminary results of the Quebec Renal Network COVID-19 Study, which Dr. Suri leads.
But those statistics don’t fully capture how dialysis patients have suffered. Interviews conducted as part of the network’s research found a distress that was harder to quantify, one that arose from being isolated at home and inside dialysis units where visitors were mostly barred as a necessary infection-control measure.
Bingo games, pet therapy, hugs from nurses – all the human touches that made hours hooked to a dialysis machine bearable – were also banned.
“Many of our patients are frail. They’re elderly, they have language barriers, they have other special needs and disabilities,” said Dr. Suri, director of the division of nephrology at McGill University. “And the visitor is often not just visiting for social reasons, a visitor is actually providing some form of health care. That piece was lost and that had impact on the patients.”
Because it can’t be quantified in the same way as a surgical backlog or a drop in emergency department visits, the emotional toll of forcing patients to undergo medical care alone is often overlooked by the public.
Kirsten Fiest, a University of Calgary epidemiologist who is leading a national research project on ICU visitor policies during the pandemic, said that interviews with patients, families and health care providers reveal the restrictions caused stress and heartache.
Most understood the policies as a necessary evil, one that couldn’t be avoided if hospitals hoped to keep the coronavirus at bay. “However, that didn’t make it any easier to have to endure,” Dr. Fiest said.
For Mr. Gomez Marin and his wife, having to be apart at key moments in their cancer journey was harder than waiting for a surgery date. Ms. Leahy-Gomez and the couple’s son and daughter had to drop Mr. Gomez Marin outside the hospital on the morning of his surgery, fearing they might never see him again.
“The worst part of this whole thing,” Ms. Leahy-Gomez said, “was when he had to go to the doctor by himself, and get that news that he had cancer.” It was just before Christmas.
On Jan. 12, Mr. Gomez Marin met Dr. Eskander at Sunnybrook to learn that he needed a 13-hour surgery on his jaw as soon as possible.
Mr. Gomez Marin wasn’t officially added to the queue until Jan. 26, Dr. Eskander explained, because he needed a CT scan of his legs to help determine what part of the body could be used to reconstruct his jaw.
In an interview before his surgery, Mr. Gomez Marin was sanguine about the wait. “I don’t know if it has been delayed or not because I don’t do this every month. I don’t know how long it would have taken without the pandemic, to be honest with you.”
Born in Barcelona at the end of the Spanish Civil War, Mr. Gomez Marin is stoic by nature, his wife said, adept at making the best of things. He is now home in Newmarket, north of Toronto, recovering.
A year into the pandemic, doctors, nurses, hospital administrators and other front-line providers remain among the loudest voices calling for lockdowns and other restrictions. It’s not because they don’t care about non-COVID-19 patients such as Mr. Gomez Marin – it’s because they do.
Last summer, when community spread of SARS-CoV-2 was low and ICUs were mostly free of COVID-19 patients, hospitals were able to loosen visitor restrictions and chip away at their surgical and diagnostic backlogs.
Provincial governments, whatever the flaws in their pandemic responses, have all presented recovery plans to address this task. Those plans will be difficult to pull off if critical care units are full of COVID-19 patients.
As Dr. Eskander and his colleagues put it in the opening paragraph of their study on Ontario cancer surgeries during the first wave: “Postponing cancer surgery may cost more lives than can be saved by diverting surgical resources and services to managing [the] coronavirus.”
With a report from Tu Thanh Ha
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