March 2021 Edition Vol.13, Issue 3

COVID-19 is a "Disruptive Innovator" for Oncology

By Aaron Tallent

Staffing shortages, evolving health regulations, and treating patients in the midst of a pandemic are just a few of the challenges the cancer community faced with COVID-19 in the past year. During a session on cancer care in the COVID-19 era at the Association of Community Cancer Centers (ACCC) 47th Annual Meeting and Cancer Center Business Summit held virtually in March, oncologists and nurses discussed how they are continuing to manage the disease, its effects on cancer care, and the lessons they’ve learned.

“We are much better prepared. We know more about the disease,” said Luis M. Isola, MD, Director of Cancer Clinical Programs at Mount Sinai Health System and Tisch Cancer Institute. “We understand some things that help and some things that don’t help.”

Beyond dealing with protective measures required for the disease, COVID-19 highlighted existing gaps in systems of care and forced practices to make adjustments that many oncology professionals hope will remain in place. The improvements range from telemedicine to patient/physician communication to waiting rooms.

“My hope is that [COVID] will continue to be this disruptive innovator for us,” said David W. Dougherty, MD, MBA, Medical Director of Dana Farber Cancer Institute Network.

The Effects of Delayed Cancer Care

While COVID-19 has produced innovation, its impact has been severe. Early on in the pandemic, physicians had to tier procedures such as major surgeries based on need and clinical trials were put on hold. Many cancer patients were cancelling appointments or just not showing up for them out of fear of the virus. In this environment, routine care and screenings became an afterthought.

Now, oncology professionals are beginning to see the effects of those delays. Mary Miller, MSN, RN-BC, OCN, Nurse Manager of the Franciscan Health Cancer Center in Indianapolis, said that outreach conducted by her practice has encouraged more people to resume their screening, but cancer has either developed or progressed in some patients. She is seeing this particularly in more young women being diagnosed with late-stage ovarian cancer.

Miller indicated that for patients who put off screening, “We’ve seen some really ugly situations that are very heartbreaking.” Dr. Isola also noted that the delay in screenings are concerning, and the full effect of people not being screened is going to be felt for years. “It’s not going to become evident in the next few months. It’s going to become evident in the next few years,” he said.

COVID Causes Staff Burnout and Shortages

The threat of contracting COVID-19 has been a major point of stress for oncology professionals. The Centers for Disease Control and Prevention (CDC) reports that more than 445,000 health care workers have had COVID-19 and more than 1,400 have died. When a colleague is diagnosed with the virus, nurses and physicians are forced to take on additional patients and shifts, while processing the fact somebody they work with has COVID-19.

“That put an extraordinary burden on the people who stayed behind,” said Dr. Isola.

COVID-19 diagnoses have also contributed to long-term staff shortages. Jody Pelusi, PhD, FNP, AOCNP, an oncology nurse practitioner at Honor Health Research Institute in Scottsdale, AZ, went to the emergency room with shortness of breath, chest pains, and chills and was diagnosed with the disease.  While she survived, Pelusi has not fully recovered and has been on short-term disability for nearly four months, unable to return to work or have contact with her patients.

“My perspective is very different than what I thought when I was just taking care of patients,” she said.

Even with the vaccine, oncologists and nurses have been working longer hours, having to take extra precautions with their health, and dealing with last-minute staffing changes. They are doing this while managing childcare and the challenges their spouse or other loved ones may be facing. Many, especially nurses, are exploring career changes or becoming travel nurses who work in short-term health care facilities around the world and can make up to five times their current salary.

“We’ve been on a rollercoaster for a year now just trying to keep staff happy, trying to keep them from quitting, trying to keep them from jumping on the travel nurse bandwagon and going everywhere,” said Miller.

Practices are trying a number of ways to support their employees physical and mental health. Northwest Medical Specialties, PLLC (NWMS), which has five locations in the Tacoma, WA, area with 250 employees, created a hardship program where individuals donated their paid time off (PTO) to a general fund. The PTO was then allocated as extra leave time to employees who were dealing with personal challenges.

“When I talk about it, I get goosebumps. It was such a great effort,” said Sibel Blau, MD, Medical Director of NWMS and President and Chief Executive Officer of the Quality Cancer Care Alliance.

Oncologists Embrace Telemedicine 

Anyone who has been in a doctor’s office in the past year has seen firsthand the health care changes that range from staff dressing in full personal protective equipment (PPE) to everyone being screened with temperature checks before entering the building. Perhaps the most significant innovation to become widespread during the pandemic was the use of telephones and video conferencing to conduct care. This practice, known as telemedicine or telehealth, allows patients and providers to safely meet and cuts down on commute time.

In 2020, the Centers of Medicare and Medicaid Services (CMS) provided greater flexibility in using telehealth due to COVID-19 and oncology professionals have utilized it to the fullest extent during the pandemic. For example, NWMS has moved all appointments to telemedicine where feasible and Mount Sinai, who conducted only eight telehealth visits in January and February of 2020, held nearly 17,000 over the remainder of the year.

Practices are also utilizing virtual tools for inpatient visits. Friends and family members who take patients to see their oncologist are now allowed to participate in the visit from the car via their tablet or smartphone. If they do not have a device, the practice provides one.

The ACCC session participants did note that inequal access to care also impacts telemedicine. Patients who live in rural areas or have lower incomes often have internet connectivity issues, which diminishes their opportunities for virtual visits with their physician.

“We couldn’t really do telehealth with many of our patients because they don’t have access to Zoom. They don’t have access to MyChart. They’d have trouble even coming to see us face-to-face because they don’t have a car or they have to take public transportation,” said Adam Riker, MD, FACS, Chair of Oncology at Anne Arundel Medical Center: DeCesaris Cancer Institute in Annapolis.

Dr. Riker said a poll of his patients revealed that recently diagnosed individuals need at least one face-to-face visit with their physicians, but a wide swath can also be managed through telemedicine. It is also critical for CMS to sustain and enhance its rules post-pandemic for telemedicine to continue and thrive.

One challenge with telemedicine can be the upfront cost. Practices have to pay upwards of $10,000 to purchase a platform, which is on top of additional tablets they have had to buy. However, Dr. Blau points out that this technology is becoming an integral tool to make sure all patients have access to high quality care.

“Certainly, not all institutions can afford giving everyone iPads to take home after they become our patients, but we could and should bring this to even the remotest places in the country so everyone has a similar access to care,” she said.

Will Telemedicine Mean the End of the Waiting Room?

Telemedicine is one innovation that will continue after the pandemic. Another likely one is the end of the waiting room. With the different scheduling changes of the past year, practices and patients are seeing that they can do without it.

“I’m glad that waiting rooms are gone because remember even before COVID, [they] were one of the most frequent patient dissatisfiers with people having to wait in the waiting area to see their doctor,” said Dr. Riker.

With more people receiving one of the three COVID-19 vaccines available, the end of the pandemic seems feasible to millions of Americans. Although many in the oncology community expect a return to normalcy sometime in 2022, they do not simply want to go back to practicing medicine like it’s 2019.

“We really have to embrace those lessons learned so that we don’t fall back into our sort of comfortable place of how we used to provide care and take these experiences and really truly learn from them,” said Dr. Dougherty.

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