August 2020 Edition Vol.11, Issue 8

COVID-19 and Cancer: Anticipating the Future of Care

By Lynne Lederman, PhD

As the pandemic of SARS-CoV-2 viral infections continues with no end in sight, two recent oncology virtual meetings addressed the effect of COVID-19 on cancer care, with an eye on some possible solutions.

Two Community Practices Adapt

During the Community Oncology Alliance (COA) Advocacy Summit: Cancer Care in a COVID-19 World, held on July 15, 2020, Barry Russo, MBA, Chief Executive Officer, The Center for Cancer & Blood Disorders, Fort Worth, Texas, and Anthony Scalzo, MD, President, Hematology-Oncology Associates of CNY, in upstate New York, discussed how cancer care may change post-COVID-19. Their top ten future considerations for oncology in the Covid world were presented (see Box below), followed by discussion on how their community-based practices are adjusting.

Top Ten Future Considerations for Oncology in the Covid World
  1. Testing: IgG/PCR
    • When?
    • How to risk stratify patients and staff for testing?
  2. Telemedicine
  3. Patient electronic communication systems
  4. Covid/infectious screening of patients and visitors
  5. Surgical services
    • Ambulatory (in clinic) to keep patients out of hospital
  6. Isolation of positive or possibly positive patients
  7. Management of high-risk populations
    • Separate treatment areas
    • More electronic connectivity
    • Consistent and formal interaction with skilled nursing and rehab facilities and prisons
  8. Interaction with and inclusion of family members/caregivers not accompanying patients
  9. Disinfection and safety
    • Waiting rooms, infusion suites, radiation/radiology dressing rooms
  10. Patient education in a virtual world

Both practices have been relying heavily on telemedicine visits, with reliance on caregivers and phone calls for those without access to technology. Solutions to bring patients safely into the clinic include no-touch thermal imaging, requiring masks, installing air filtration and UV disinfection systems, enhanced cleaning, and limiting or eliminating visitors.

For nursing homes and rehab facilities, most patients are not on active care and telehealth is possible if not ideal. However, for federal prisoners in the Forth Worth area who are being treated by Mr. Russo’s practice, telehealth is not an option because phones aren’t allowed in prisons, even for therapy. This is compounded by a high rate of infection, particularly among male prisoners. “We need to figure out a separate treatment area,” he said.

Dr. Scalzo’s practice was in the process of renovating, and was able to add two negative pressure rooms where patients possibly ill with COVID-19 are seen.

Mr. Russo’s practice has closed off meeting rooms for potentially virus-positive patients, although a more formal space is needed, not just for COVID-19, but for influenza and other infectious diseases. Both acknowledged an “aha” moment that COVID-19 brought to the fore. “We should have been thinking about this before for immunocompromised patients,” Mr. Russo said.

Mr. Russo thinks the future of patient education will be app-based. Dr. Scalzo says patient education information is on their web site, and is also mailed.

Bringing Patients Back to the Clinic

At the American Association for Cancer Research (AACR) COVID-19 and Cancer Virtual Meeting, held July 20 – 22, 2020, a panel discussion moderated by Nancy E. Davidson, MD, Fred Hutchinson Cancer Research Center, Seattle, Washington, addressed how to bring patients back to the clinic.

Howard A. Burris, MD, Sarah Cannon Cancer Center, Nashville, Tennessee, said that the use of telehealth has reduced patient numbers in the clinic and reduced the infection risk. However, it is still not an option for those without internet access, which is diminished for those who live at a distance from cities, and it’s “hit or miss” for older patients. Nevertheless, he’d like to make telehealth an ongoing part of care despite payers thinking telehealth is susceptible to fraud.

Dr. Davidson asked about patients delaying care or screening because they are too afraid to come in due to COVID-19. Dr. Burris mentioned two patients who delayed visits, one of whom died of a usually treatable form of leukemia, and another who is still treatable but whose lymphoma is at a more advanced stage after a delayed diagnosis.

Dr. Davidson commented that providers need to get the “message out that clinics are pretty safe,” and bring patients back since SARS-CoV-2 isn’t going away.

Lisa M. DeAngelis, MD, Memorial Sloan Kettering Cancer Center, New York, NY, said during the height of the pandemic in the New York tristate area, cancer screening was down 90% and has not yet fully recovered. Patients feel well, she said, so they think it’s safe to postpone screening. She noted this would be fine for a few months when it was thought that the pandemic was monophasic; however, the virus is now “here to stay.”

Dr. DeAngelis said testing for SARS-CoV-2 is being done pre-procedure and pre-operatively for all patients, and for symptomatic staff. Although staff can be tested on demand, she has concerns about reagents and testing capacity over time. Likewise, she has concerns about personal protective equipment (PPE) to protect staff and critically ill patients, saying, “It’s clear the supply in the US is not as robust as it should be. We could run into supply issues again whether (there are) micro-outbreaks or a full-blown pandemic.”

Dr. Davidson said that one thing that brings patients into the clinic is access to clinical trials. She asked what will happen and how to invest in the future of cancer care. Dr. Burris said that just as 9/11 changed air travel, COVID-19 may modernize clinical trials. In his practice, nurses screen patients for clinical trial eligibility, and the consent process is already done remotely, as is data monitoring. More patients can participate by doing these things electronically because travel will be an issue for a long time.

Dr. DeAngelis said they have converted all clinical trial nurse encounters to electronic telehealth. Electronic consent decreases the burden on both patients and staff.

A live audio discussion was not available for this forum, however, the moderator answered questions online during the session. Dr. Davidson wrote, “It will take providers, cancer center leaders, professional societies, payers, and patients to move (telehealth) forward. I do think it is a lot easier to ‘right size’ our approach now that we are enabled to practice telehealth so widely. It is critical for all of us to figure out how to do this in an optimal fashion.”

Practices being put in place to encourage patients to resume cancer screening procedures, imaging, and preventive care could include transparency with institutional COVID-19 statistics, posting all processes for patient and staff protection on the institution’s web site, universal masking for patients and staff, thorough room and equipment cleaning, and screening for symptoms of COVID-19 and then triaging  where there is concern.

Testing continues to be challenging—who to test and for what purposes? Policies vary and are evolving. Many institutions are now testing asymptomatic patients who are facing a procedure, because a positive test has major implications for the staff as well as the patient. However, false positive and false negative test results remain a concern.

ASCO Looks at Continuity of Care

The American Society of Clinical Oncology (ASCO) established the ASCO Survey on COVID-19 and Cancer (ASCO) Registry to: 1) analyze the distribution of symptoms and severity of COVID-19 in people with cancer, 2) examine the impact of COVID-19 on cancer treatment and outcomes, and 3) document adaptations of cancer care delivery due to the pandemic.

Suanna S. Bruinooge, MPH, ASCO, Alexandria, Virginia, presented an initial report from the ASCO Registry on changes implemented by US oncology practices in response to the pandemic at another session during the AACR meeting. She focused on the third objective.

Thus far, the ASCO Registry has enrolled 31 clinical sites comprising 28 separate practices in 20 states. The survey looked at practice changes concerning telemedicine, patient management, in-office changes for physical distancing, supply shortages, and staffing changes.

Ms. Bruinooge said it was surprising that telemedicine was new to all but 2 (6%) practices. The majority of practices use telemedicine for at least some routine monitoring. All practices are accepting at least some new patients; 71% had no change in scheduling new patients. Most screen for COVID-19 in advance of and at entrance to in-office appointments. About two-thirds of practices made no changes to intravenous drug infusions, 23% switched to oral medications, 20% shortened infusion regimens and 10% halted infusions. About half of practices allowed specimen collection at or closer to patients’ homes.

In-office changes included requiring masks and excluding patient companions in all practices; most reduced frequencies and/or increased intervals of visits, added physical barriers at the front desk, and added screening triage stations. A little more than half suspended patient support activities or made them available virtually, and modified infusion areas to semiprivate.

No practices reported a shortage of anti-cancer drugs or supportive care drugs, other than shortages of opioids/controlled substances reported by one. Shortages of PPE was reported by 77% of practices, and shortages of nasal swabs for COVID-19 tests or hand sanitizers were reported by about half. Staff changes (reductions) were reported by 55% of practices; 23% were due to staff infection with SARS-CoV-2.

Ms. Bruinooge said that future reports will include patient-related data. The registry is starting to look at data for patients with COVID-19 to see if there is an effect on overall survival and cancer treatment outcomes.

A New Normal?

At the AACR meeting, Lisa C. Richardson, MD, MPH, Director, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, discussed navigating the new normal and trends shaping post-COVID-19 cancer care delivery. She said that the 20% decrease in cancer deaths over the last 20 years could be reversed by the pandemic, fueled by ongoing cuts in funding for cancer prevention and a decrease in state and local public health workforces. Since the start of the pandemic, patient visits to primary care providers and specialists have decreased by half or more. Screenings for breast, colon, and cervical cancer have also decreased and have not yet recovered. Although outpatient care visits are rebounding, they remain below pre-COVID-19 levels.

In addition to telehealth and remote patient monitoring, the universal use of masks, and limiting the number of patients in clinic at one time, Dr. Richardson suggested the use of drive-through infusions as well as doing blood draws curbside, with patients in their cars, as adaptations to this new reality. She said it is still a challenge to have people comfortable with being screened for cancer.

Another big challenge is to provide access to services for those who test positive after a cancer screening, e.g., a fecal immunochemical test (FIT) which screens for colon cancer. The next step after a positive FIT is to have a colonoscopy. Dr. Richardson has noticed people saying on social media they had a positive screening test and can’t get surgery.

Moderator Karen E. Knudsen, PhD, Thomas Jefferson University, Sidney Kimmel Cancer Center, Philadelphia, Pennsylvania, asked about reaching critical patients. Dr. Richardson said given that most care occurs in the community rather than academic centers, the CDC is trying to develop population-specific messages that speak the language of people within their culture and the places where they live.

Looking Ahead

To bring patients with cancer back into the practice setting, practices need to make sure their clinics are safe, and convince patients they are safe. Skipping screenings for and treatment of cancer is more risky than contracting COVID-19, particularly in areas of low viral prevalence. There is a critical need for a rapid, accurate, inexpensive diagnostic test for SARS-CoV-2. In many areas of the country there is an unacceptable lag in obtaining results for current viral tests. Continued current and expected shortages of PPE, testing reagents, and swabs are other obstacles. Even when patients return, telehealth won’t be going away; it can be improved by expanding access and by adding sensors to allow vital signs to be taken for the ability to listen to patients’ hearts and lungs remotely.

 

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