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People walk towards a Covid-19 Assessment Centre at Michael Garron Hospital, in Toronto, on March 15, 2020.Christopher Katsarov/The Globe and Mail

The words on the sixth page of Ontario’s pandemic plan for cancer patients are dry and bureaucratic, but there is no mistaking their weight.

In the event of a widespread pandemic, the document warns, “it is realized that even all Priority A patients might not receive prompt treatment.”

Priority A is how Cancer Care Ontario, now part of the superagency Ontario Health, describes in a pandemic plan patients whose pain is unbearable or whose situation is “immediately life-threatening.” The plan was sent to vice-presidents of regional cancer services across the province last week.

Updated on March 10 as the Canadian health-care system prepared for outbreaks of the new coronavirus, Cancer Care Ontario’s plan provides a glimpse of what could happen to some of the country’s most vulnerable patients as COVID-19 spreads further.

At the Princess Margaret Cancer Centre, Canada’s largest, oncologists are already combing through their files, searching for appointments that can be postponed.

“All of our clinicians are looking at their patient volumes and looking at who might be able to have appointments pushed out if they’re for long-term follow-up [and] who might we be able to move to a virtual assessment," said Marnie Escaf, senior vice-president and executive lead at Princess Margaret, part of Toronto’s University Health Network.

However, the cancer centre has not yet had to take the more serious steps outlined in the pandemic plan, a copy of which was obtained by The Globe and Mail.

First to go would be long-term follow-up appointments for cancer survivors, routine screening for breast, colon and cervical cancer, genetic testing related to cancer, and clinics for patients with non-melanoma skin cancer, according to the document.

Cancer patients would be divided into priorities A, B and C, with patients in the C category the least likely to need – and to receive – treatment or surgery right away.

A surgical patient with an obstruction or bleeding that requires immediate surgery would count as priority A, as would patients who had been receiving chemotherapy or radiation to shrink a tumour before surgery.

Most patients with solid tumours would count as priority B, “provided delays were in the range of 4 weeks."

Patients with some thyroid cancers, early prostate cancer and non-melanoma skin cancers would be relegated to priority C.

Patients who disagreed with their category would have the option of appealing to “a local appeals committee made up of the Medical Director, the relevant Program Director, a bioethicist if available and others felt relevant to the particular decision.”

Still, cancer surgeries are less likely to be delayed than other types of operations.

In a memo about the cancellation of elective surgeries sent Tuesday to doctors in the Calgary area, Alberta Health Services wrote that, “It is expected that the pandemic will continue for several months, and as such, stopping oncological surgery at this time does not seem appropriate.”

Sandra Krueckl, vice-president of cancer control for the Canadian Cancer Society, said news of cancellations and postponements has only started reaching cancer patients.

“It’s always concerning when we have a scenario that forces [cancer agencies] to reduce or change access that people have to care. These are really challenging times,” Dr. Krueckl said. "It does become necessary to think proactively about how we can best serve everybody.”

Keeping the coronavirus out of cancer centres is another top priority, according to Bob Bell, a former Ontario deputy health minister who was chief operating officer at Princess Margaret in 2003 when SARS forced physicians to evaluate patients with respiratory symptoms in a makeshift assessment area behind the hospital.

“We had oncologists literally have discussions about patients on the sidewalk wearing ski jackets, stethoscopes hanging from their necks,” he said. “They made the right diagnoses. We did not get SARS at Princess Margaret Hospital."

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