In It for the Long Haul

The virtual forum ​was titled “How Will We Bring Patients Back to the Clinic?” but moderator Nancy Davidson, a breast cancer oncologist and senior vice president and director of the Clinical Research Division at the Fred Hutchinson Cancer Research Center in Seattle, kicked off the discussion by suggesting the phrase “and Keep Them in the Clinic” be added to the end. “We now know that the COVID pandemic will be with us for some period of time,” said Davidson, who is also president and executive director of the Seattle Cancer Care Alliance.

Davidson’s July 21 forum was part of an online meeting on COVID-19 and cancer held by the American Association for Cancer Research, which publishes Cancer Today. Amid rising COVID-19 cases in the U.S., oncologists, researchers and others checked in with each other, discussing how they can best assure their patients get proper care going forward. They talked about their concerns both in the forum and in a symposium preceding it on continuity of cancer care.

Looking Back

During the symposium, doctors and researchers discussed how COVID-19 affected cancer patients in the early months of the pandemic. Medical oncologist and internist Gary Schwartz, who is chief of hematology and oncology at Columbia University Medical Center and deputy director of the Herbert Irving Comprehensive Cancer Center, provided an introduction for the symposium, describing his institution’s experience in New York City, where COVID-19 cases surged in April. He said that around 400 cancer patients at Columbia were diagnosed with COVID-19, and more than 18% of the cancer patients died, a mortality rate he said was relatively high. Half of patients in the neighborhood of Columbia are born outside the U.S. and 20% live below the poverty line. “Our community was especially susceptible to the risk of COVID-19, illustrating and reinforcing the need to understand the lessons learned of how we can go forward and how cancer care needs to be continued in the face of the pandemic,” Schwartz said.

​​Researcher Suanna S. Bruinooge of the American Society of Clinical Oncology (ASCO) in Alexandria, Virginia, presented data from an ASCO survey of 31 oncology practices in 20 states on how the pandemic affected cancer care in recent months. The survey is ongoing and continues to enroll oncology practices. Bruinooge and her colleagues found that all practices required masks, discouraged family or friends from accompanying patients to their appointments and used telemedicine for some visits. Further, 87% reduced the number of visits for their patients or increased the intervals between visits.

When it came to infused drugs, 10% reported halting infusions at some point during the pandemic, 26% shortened the duration of infusions and 23% switched some patients to oral drugs. Nearly half of the practices allowed patients to have laboratory specimens collected at alternate locations, mainly telling patients they could do labs at locations closer to home.

“Oncology practices have made significant and rapid changes to care delivery because of COVID-19,” Bruinooge said. “In many cases these changes were made to prioritize and promote patient safety.” Oncology practices also reported that they were affected by shortages, with 77% saying they experienced shortages of personal protective equipment (PPE), 52% reporting shortages of medical hand sanitizer and 45% saying they had shortages of nasal swabs for COVID-19 tests.

Researchers also discussed the new role of telemedicine in cancer care. For 94% of the practices that responded to the ASCO survey, telemedicine was new. Davidson echoed this sentiment in the forum. “I went from never doing it in my life to being trained and certified to do it in 10 days,” she said. “And I’ve been an oncologist for 30 years and I never ever, ever thought I would see that.”

Hematology and oncology fellow Elad Neeman from Kaiser Permanente San Francisco Medical Center presented research on telemedicine during the pandemic in the Kaiser Permanente Northern California system. In February 2020, 60.3% of medical oncology visits in the system were office visits. This number decreased to 2.3% in April and then rose slightly to 5% in May.

Medical oncologists mentioned easing of financial burden and convenience to caregivers as benefits of telemedicine. However, they also complained of technical issues, such as equipment troubles and connection problems. Among types of visits that could be done via telemedicine, medical oncologists were least likely to find it acceptable for discussing a new diagnosis or discussing end-of-life care, with almost half saying only an in-person visit would be acceptable. Around 11% of medical oncologists said that they felt a patient experienced an adverse event that may have been prevented by an in-person visit.

Finding a Balance

Health care systems and oncology practices made changes at the beginning of the pandemic to protect patients and staff and to buy time to improve their supply chains and develop new procedures. Some changes remain in place, like increased telemedicine. Neeman said that the key going forward will be understanding when telemedicine is the right choice and when an in-person visit is warranted. “For different types of activities, we can use different types of visits,” he pointed out. “We don’t have to switch everyone to video.”

Surgeon and breast cancer oncology specialist Laura Esserman, who is director of the University of California, San Francisco, Carol Franc Buck Breast Care Center, noted during the symposium that some changes to treatment, like increased use of systemic treatment before surgery, are also sustainable and positive and were already being adopted by major centers prior to the pandemic.

However, other changes to care are not sustainable, the researchers said. Treatments cannot be pushed off indefinitely in most cases. And it’s one thing to postpone screenings​ for a few months but care should not continue to be pushed off, said neuro-oncologist Lisa M. DeAngelis, who is physician-in-chief at Memorial Sloan Kettering Cancer Center in New York City, during the forum. “We all have to learn to coexist with the coronavirus and yet continue all of the regular health care that’s so essential,” she said.

Esserman said during the symposium that social isolation is one of the most challenging things about the pandemic and should not be overlooked. “Having the support of loved ones is an essential part of care,” she said. She urged her fellow doctors to include caregivers in telemedicine and in-person appointments virtually and also to try to think of safe ways to let a caregiver accompany a patient to surgery, such as having the caregiver get tested for the coronavirus in advance just as patients getting surgery are now tested.

There is also concern that patients are delaying addressing problems due to concern about going to a medical center during the pandemic. Medical oncologist Howard “Skip” Burris, chief medical officer of Sarah Cannon in Nashville, Tennessee, during the forum told the story of a patient who was sick for eight to 10 weeks before coming to the emergency room. He died of acute promyelocytic leukemia, which is generally curable. Another patient had testing delayed only to later find out she had mediastinal lymphoma, which will be treatable but was more extensive than it would have been if found earlier.

“The clinics are pretty safe now and you need to attend to your general health,” said Davidson.

Care in Context

Toward the end of the forum, Davidson said she had a question that “all of us are probably thinking in the back of our heads.” Are there events that could require cancer care to ramp down again?

Infectious disease physician Catherine Liu of the Fred Hutchinson Cancer Research Center, who is the associate director of infection control at the Seattle Cancer Care Alliance, said that while there aren’t formal national guidelines explaining what situation would call for certain care to be dialed back down, she and other infectious disease experts are looking at metrics like local COVID-19 test positivity rates, trends in local COVID-19 cases, hospital capacity, ICU capacity, staffing and supplies of key items.

During the symposium, speakers also emphasized the significance of watching current conditions in one’s local area. Esserman presented a series of calculations she had done showing that, in the San Francisco Bay Area where she practices, the benefits of breast cancer screening and treatment should outweigh the risk of contracting COVID-19 by coming to a medical setting. For instance, she stated that for a person driving to their appointment in San Francisco in early July, the chance of getting COVID-19 would be 100 times less than the chance of finding an early cancer through screening and the chance of dying from skipping cancer treatment would be 1,000 to 100,000 times greater than the risk of getting COVID-19 and dying because of coming to treatment. However, she noted that the risk of COVID-19 will rise if the rate of infections rises, if a patient takes public transit and if the health care facility isn’t taking precautions, such as using masks.

The final speaker at the symposium, medical oncologist Lim Soon Thye of the National Cancer Center in Singapore, spoke about the adaptations his center made, noting how cancer doctors and the Singaporean government took lessons from the SARS epidemic in 2003 to face the COVID-19 pandemic. Overall, there have been 27 deaths from COVID-19 in Singapore.

When asked about the lessons of the pandemic, Thye emphasized the role of the larger community in creating conditions for success. “We cannot be separate from the larger community,” he said. “If the community doesn’t get it right, if the country doesn’t get it right, it’s not going to be possible for a single institution to get this right. It has to be a coordinated response.”

To close out the session, Esserman reflected on how the U.S. can do better at responding to the pandemic, and the larger role researchers have to play. “I think there’s a very stark contrast between what you experienced [in Singapore] and the United States has experienced,” Esserman said. “We should not accept this as the way to do things going forward, and we all as scientists and physicians need to stand up and demand change.”​

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