Rapid changes, critical unknowns in cancer care amid COVID-19
The National Comprehensive Cancer Network released recommendations to keep patients with cancer, their caregivers and health care workers safe amid the COVID-19 pandemic.
The recommendations — published in Journal of the National Comprehensive Cancer Network — include strategies to minimize risk for COVID-19 transmission and reduce morbidity and mortality associated with the novel coronavirus while also ensuring high-quality cancer care can be delivered.
The guidance helps reassure oncology providers that they still have control over several aspects of care that can improve outcomes for their patients, according to lead author Pelin Cinar, MD, MS, medical director of quality and safety at UCSF Helen Diller Family Comprehensive Cancer Center.
“We remain committed to continuing to care for our patients with cancer during this pandemic, including their mental health,” Cinar told HemOnc Today. “We want our patients to know that we understand the stress they are under and we will continue to be here for them. We are doing everything in our power to not jeopardize any of their cancer-related outcomes during this unprecedented time.”
Cinar spoke with HemOnc Today about how COVID-19 has impacted cancer care, the biggest challenges she and her colleagues in oncology have faced trying to treat patients amid the pandemic, and key elements of the NCCN guidance.
Question: Can you describe the impact COVID-19 has had on cancer care, both in terms of how treatment is delivered and efforts to protect patients from COVID-19 infection?
Answer: Early on, the biggest challenge was the uncertainty associated with COVID-19. We did not know what kind of surge we were going to get or how to prepare for it. We had to quickly start to think of innovative ways to deliver the critical care to our oncology patients. Our earliest intervention was transferring in-person business to telehealth visits in order to reduce the number of times patients were coming into the cancer center. We also implemented screening for patients with cancer and their visitors who had any concerning COVID-19 respiratory symptoms. We directed patients to clinics that we set up, dubbed respiratory screening clinics, in which they would be triaged and evaluated appropriately. Clearly the impact has been huge, and we have continued to think of more creative ways to deliver the oncology care that we normally provide.
Q: From an oncology standpoint, is this situation continuing to evolve rapidly?
A: This depends on where you are in the nation. We are very lucky in San Francisco, because we pretty much flattened the curve already. Our numbers have been very stable, especially at UCSF, and we are not seeing a big surge — although we were ready for it. Things are starting to improve and we are developing recovery plans to thoughtfully start seeing patients in clinic again and opening up the operating rooms for surgeries. On the other hand, our colleagues on the East Coast — in Boston and New York, for example — are still struggling every day with more COVID-19-related issues, so they probably will be having these discussions in the next few months.
Q: What have been the biggest challenges you and colleagues in oncology have faced trying to treat patients with cancer amid the COVID-19 pandemic, and how are you trying to overcome those challenges?
A: We have had to rapidly change the way we deliver care while continuing to acknowledge critical unknowns of how these changes affect clinical outcomes. The most challenging aspect is that we have to take everything in a slower stride. For example, when we have a planned surgery, we become a lot more mindful and thoughtful about how we plan to care for each patient. The discussions between multidisciplinary teams that occurred prior to the pandemic have been even more pronounced and more detail-oriented so that we can determine the sequence of treatment plans for our patients. Regarding the care continuum for each patient, we need to decide if we are going to give more upfront care with chemotherapy or radiation therapy when we normally might have performed surgery. All of these decisions are still made in an evidence-based manner as much as possible with supporting data. The biggest challenge has been not being able to provide the type of high-quality care we are used to delivering effectively and efficiently in a rapid manner. We have worked hard to overcome that with mitigation plans in an effort to not jeopardize patient outcomes.
Q: Can you speak to some of the challenges that are unique to specific subsets of patients and best practices for caring for these groups?
A: Patients undergoing bone marrow transplantation are at highest risk due to their immunocompromised state. When testing was limited, they were among the first groups we tested for COVID-19 — even if asymptomatic — as they were being admitted to the hospital to undergo bone marrow transplants. We wanted to minimize any potential consequences if they underwent a bone marrow transplant and then had complications from COVID-19.
Another challenging group is the patients with cancer who have COVID-19 and require anti-cancer treatment that cannot be interrupted. Treatment for these patients has to be weighed against the risk for developing complications from COVID-19. We developed a protocol that allows these patients to continue to receive their cancer treatment despite having COVID-19 while taking into account their safety and that of the health care staff and other patients. An example of this is patients with head and neck cancer who may be in the middle of radiation therapy. We would prefer to not stop radiation therapy because it may be detrimental for their outcomes.
Geriatric patients with cancer are another vulnerable population. It has become quite important that they practice social distancing and shelter in place. However, the mental health of those individuals is a major concern because — if patients are social distancing — we do not want them to go through social isolation. A lot of these patients have experienced social isolation, and we have developed several different interventions for that. Our social workers are very involved with those patients who are at high risk for social isolation, and there are multiple resources available for them.
Q: Do you think the increased use of telehealth during the COVID-19 pandemic will prompt a long-term shift toward greater utilization in cancer care delivery?
A: It helped that certain reimbursement models were broadened through the CMS, which allowed a lot more people to participate in telehealth. Our UCSF telehealth program had the second-highest use of telehealth visits among academic medical centers across the nation prior to the pandemic, and our volume has increased tremendously. A contributing factor to whether this will continue is dependent on whether CMS changes its coverage of telehealth. The hope is that the way we are using telehealth now will allow CMS to see what a great service this is for our patients and the type of care that we can deliver to them safely and effectively at home. Previously, CMS was only covering telehealth for patients residing in rural areas and it could not take place in their home. But, we certainly hope that there will be changes in both the reimbursement models and the way different institutions have adapted to telehealth to allow for wider and sustained use of telemedicine.
Q: How challenging is it for clinicians to distinguish between essential and nonessential treatments, appointments and consults?
A: For office visits, almost any follow-up visit that we do can be done over telehealth. If the patient has a specific physical complaint that requires a physical exam, the patient would still be seen in person, recognizing the increased risk for exposure. The majority of patients, however, do not want to come to the cancer center unless they have to for procedures, studies or an infusion.
The definition of essential or nonessential procedures and surgeries should be created in a standardized and multidisciplinary way to not allow just one provider’s subjective concept of what is essential or nonessential. For us, it was very important to gather each disease group together and have multidisciplinary discussions about how we would prioritize patients and follow the three CMS tiers. As we would normally discuss a complicated case during a tumor board, we came up with specific priorities for each disease group. This allowed for an understanding among everybody who treats that patient. This ultimately may allow us to know whether our outcomes will differ because we made these treatment recommendations under the pandemic circumstance.
Q: The NCCN recommendations cite specific cases when treatment plans can be modified. What factors need to be considered to make those changes?
A: Not every regimen can be modified, but there are data for certain types of regimens that can have alternative dosing schedules — every 2 weeks vs. every 4 weeks, for example. We looked for guidance from both our pharmacists as well as our physician champions at the cancer center on what regimens could be modified so that patients may come to the center less frequently. The pharmacy group developed a report in which each provider had a list of their patients on those regimens. Physicians could then decide whether to modify treatment for their patients. The treating physician decided this on a case-by-case basis, once again trying to minimize any detrimental effects on patient outcomes. A great example of this is pembrolizumab (Keytruda, Merck), which is normally given every 3 weeks. However, some data suggest it can be given every 6 weeks at a higher dose with the same response. This is approved in Europe, but not yet in the U.S. Some of the faculty members asked if we could switch over to every 6 weeks, because that would reduce the number of times the patient has to come to the center. We then investigated whether insurance would cover it and, sure enough, some did.
Q: What elements of the guidance do you feel should be emphasized, and is there important information that clinicians may not already be thinking about?
A: Mental health may not be the top priority on our minds because our biggest concern is how we will continue treating patients with cancer with limited resources in this uncertain time. However, well-being and management of stress deserve a bit more focus. Patients are already going through so much. There was so much uncertainty before the pandemic with their cancer diagnosis and on top of this, we add COVID-19. It is another layer of anxiety for them, and we have to recognize this even if we simply ask them to talk about their feelings and provide them with the resources available. Most of the support that we can provide can be done with telehealth.
Q: If a patient with cancer tests positive for COVID-19, what factors determine whether cancer treatment should continue or be delayed?
A: For aggressive cancers, treatment cannot be interrupted, and those patients should continue to receive their therapy when possible — especially if COVID-19 is stable. The way to treat these patients is to be well-organized and coordinated to reduce the risk for transmission to staff and other patients.
For example, with radiation oncology, we have scheduled patients with cancer and COVID-19 to come to the clinic at the end of the day. They arrive through a separate entrance and are escorted into the building. There is a limited number of staff caring for that patient and, as soon as their treatment is complete, environmental services staff comes in and thoroughly cleans the room.
We also created an area at our respiratory screening clinic with designated rooms for patients to continue receiving infusion therapy. Our COVID task force developed a workflow in which patients receive specific instructions before they come to the cancer center. The patient is escorted along an uncommonly traveled route to an elevator that’s designated for the respiratory screening clinic only. They are then escorted to the screening clinic and taken into a room where they receive their chemotherapy. They are set up with an iPad with access to Zoom so staff will have the least amount of in-room contact with the patient but still be able to communicate with them in real time. After their therapy is completed, the patient is escorted out of the cancer center. Designating a specific area for them to be treated may lower the chance that others will be exposed to COVID-19.
Q: Have you heard of any resistance in the medical community toward treating individuals with COVID-19 who also have cancer?
A: Simply having a diagnosis of cancer does not constitute that patients will not receive treatment for COVID-19 or receive the supportive care they need. There needs to be a panel that evaluates these patients on a case-by-case basis because it has to be as objective as possible. It is hard to do that when faced with ethical dilemmas, but there has to be some way to standardize the approach. In areas that did not experience a big surge, such as San Francisco, this topic is not as relevant because the resources are not as limited as they are in New York. Many institutions, including ours, have developed ethical committees to address these kinds of questions if a surge were to be encountered. Many of our patients with cancer are concerned because they think that if they go into the ED and say they have cancer and COVID-19, that they might not be prioritized because of their cancer diagnosis, but that is not a generalizable statement.
Q: Can you offer any guidance for center leadership about the importance of communicating with staff and patients?
A: Transparency is important. Early on, new information on guidelines and policies were evolving so rapidly. We identified leaders across the cancer center and meet with them every day. Our administrative directors also communicate with their staff and we have town hall meetings, which are open to everybody and allow us to answer questions and provide updates. – by Jennifer Southall
Cinar P, et al. J Natl Compr Canc Netw. 2020;doi:10.6004/jnccn.2020.7572.
For more information:
Pelin Cinar, MD, MS, can be reached at UCSF Helen Diller Family Comprehensive Cancer Center, 550 16th St., 6th Floor, Box 3211, San Francisco, CA 94143; email: firstname.lastname@example.org.
Disclosures: Cinar reports no relevant financial disclosures.