Expert Addresses Oncology Practice Concerns Amidst COVID-19 Outbreak in the United States

Andrew M. Evens, DO, MSc

Andrew M. Evens, DO, MSc

The concerns of coronavirus 2019 (COVID-19) continue to come up in oncology practice, particularly when dealing with patients who are elderly or are actively receiving chemotherapy that causes their immune system to be compromised. While COVID-19 poses new challenges in the clinic, physicians and hospital staff are taking many precautionary steps to ensure the safety of all patients with cancer, as well as their healthcare providers and families.

Day-to-day routines have shifted in light of the COVID-19 outbreak, but patients are still receiving treatment as necessary andclinical trials continue enrollment. However, many precautions have been taken and will continue to adjust with the health and safety of patients and the general public at top priority.

In the Robert Wood Johnson (RWJ) Barnabas Health system, patients in the outpatient setting have been limited to 1 family member for visits, and these family members are also screened via phone call prior to their visit. A COVID-19 screening table has also been set up on-site to screen patients and family members as they enter the hospital.

Telemedicine is playing a large role in the oncology practice today across the health system in New Jersey, according to Andrew M. Evens, DO, MSc. At his institution, web meetings are being held daily with multidisciplinary teams across institutions to share best practices and keep each other informed on what is going on.

“Our primary concern is our patients, but of course we do not want the healthcare providers to become ill and need to be quarantined,” said Evens, director of the Lymphoma Program and associate director for Clinical Services at the Rutgers Cancer Institute of New Jersey. “We are being very cognizant of that and are just trying to work together as a team to help this.”

In an interview withTargeted Oncology, Evens discussed how COVID-19 is impacting the oncology practice as a whole, as well as in the RWJ Barnabas Health system. He highlights the importance of telemedicine at this time and the precautions that are necessary to ensure the safety of all patients with cancer, as well as healthcare providers.

TARGETED ONCOLOGY: How do you see this impacting oncology practice?

Evens:It’s an extra infection that we have to deal with and be mindful of. Even before COVID-19, we have always had a significant concern about the risk of any patient with cancer contracting an infection, in particular, those patients on active treatment and especially if they are receiving strong chemotherapies where their immune system will be compromised. With COVID-19, we are not sure if there is a higher risk of contracting an infection, but if your immune system is compromised and you happen to contract an infection, it can be more severe.

TARGETED ONCOLOGY: How has this been impacting the day-to-day routines in your institution?

Evens:Many weeks ago, we had established something for our cancer center, as well as the whole oncology service line, including all hospitals and cancer practices associated with RWJ Barnabas service line. We are making sure that we are all communicating and dealing with this together. It is affecting us here and in practices with similar guidelines that everyone else is dealing with as it relates to social distancing. Of course, in a busy oncology clinic, at any other prior time, they are often not as detailed in social distancing. That is 1 thing we are looking at. Of course, [we are evaluating] if any of our active patients are potentially ill or could have contracted COVID-19, so we have a certain screening policy where we are calling patients by phone.

We also have a table and area set up to screen patients and family members as they come in. We have also restricted the number of family members in the outpatient setting. Before, there was not a limit and at least during this current national crisis, it is restricting to 1 family member per patient. Even for the 1 family member per patient, we are calling ahead and talking to them before entering our clinic.

In terms of once they are there and for patients under active treatment, this is very individualized. There is not an overarching or 1-size-fits-all treatment policy. It depends on the individual patient, what type of cancer they have, the type of treatment they are receiving, and if it’s a cancer that could be potentially delayed or if it is a cancer that is a life-threatening cancer that is treatable and curable so we need to stay on schedule. At the end of the day, it becomes very individualized.

TARGETED ONCOLOGY: How has this impacted the enrollment of clinical trials or the treatment of patients on clinical trials?

Evens:It depends somewhat on the specific cancer. The volume is down a little bit, but that is more on us trying to control the volume. We are trying to control the volume of patients who are well and on long-term survivorship, not on active treatment. Cancer is not waiting or stopping because of this virus; it is still there, and it is still an issue. We are trying to address it in any and every way, so if there is a cancer that needs treatment, we are exploring all options, including clinical trials if it makes sense for the patient in that particular situation. We haven’t seen a decline yet regarding that part of it, in other words for patients who need treatment and are looking for potential clinical trials. At least right now, this has not changed.

TARGETED ONCOLOGY: What are the biggest challenges you see in your practice, and what steps are being taken to overcome these?

Evens:This is an additional risk to our patients. There are other potential infectious risks that we are still dealing with, such as the fact that we are still in the influenza season. We have patients still being diagnosed with influenza, so COVID-19 is an extra infection that is on the table that we have to be very cognizant and mindful of.

The other challenge is because of this, and it does look potentially more contagious and more severe even in patients who are not immune-compromised, it impacts us by all of these extra precautions we are taking with patients.

There also is some information out there already on social distancing, but I think the federal and state levels are doing a good job at communicating, especially in the last week or 2, the importance of social distancing and anything related to that. We are trying to communicate that to patients and families, including family members. Our reports for this are [showing COVID-19] is more prominent and significant in older patients, but we are trying to make sure everyone knows you can still get sick when you are younger. Even if you do not get sick, you should be mindful that you are a carrier, and you can transfer the virus to someone who is older or who sick and cannot deal with it as well. We have to make sure the messaging gets throughout for our patients and the community.

TARGETED ONCOLOGY: Are there any resources out there that can help guide community oncologists in this pandemic?

Evens:We certainly want to leverage the federal and state resources of different information. One additional resource is telemedicine, which we are actively harnessing starting last week, and we are now ramping up in the coming days. We have started this last year, and we didn’t advertise it, though we had worked on it for about a year. We started a second opinion challenging cases consult program through telemedicine. As I alluded to, we have an 11+ acute care hospitals throughout the state of New Jersey, so some hospitals are many hours apart. As part of this hospital system, we are fortunate at the RWJ Comprehensive Cancer Center to have a multitude of national and international experts across a number of different cancers. Last year, we were mindful of how we can do a better job of exporting expert opinions for patients who might be a couple of hours away and, whether due to their age or social situation, cannot drive to garner a second opinion or get additional advice on how to manage their cancer.

That has and continues to go very well, and we are doing this in collaboration with American Well. We have that experience, but obviously, this is a whole new arena now. RWJ Barnabas Health and the Rutgers Cancer Institute are launching an all-hands-on-deck telemedicine project. It will be mainly for existing patients, regardless of diagnosis or disease and not just for cancer. We will be utilizing telemedicine to care for patients who do not need to be here in person or who need to triage a situation or a question, be it related to COVID-19 or not.

TARGETED ONCOLOGY: If you could share any advice with a community oncologist at this time, what would it be?

Evens:The focus should be on the education of what is going on with the virus but also regarding the needed precautions. As we have already mentioned, social distancing and other standing ramifications [are important] regarding not only contracting but potentially spreading this virus, as well as other infections. We also do not want people to overreact at the same time, especially if they have a treatable and curable cancer because it is true that the actual risk, for not only cancer patients but for the average citizen to contract this, is still relatively low. We do not want somebody with a potentially treatable and curable cancer to forego therapy out of fear of this situation. That goes back to communication with the healthcare providers and patients, their individual situation, whether they need treatment, or if they do need treatment, what are the extra precautions to try and help their immune systems.

TARGETED ONCOLOGY: What is your takeaway message on COVID-19 in the oncology practice?

Evens:I hope other health systems are doing this, but we established multiple weeks ago our own additional COVID-19 Cancer Task Force. We have multidisciplinary web meetings, so we are not meeting in person for social distancing purposes. These meetings include 50 or more doctors, nurses, and administrators across the entire health system, where we will meet every day and talk, program by program, to understand what is going on and to share best practices. We have not gotten to the situation yet where we will need to share support or our workforce, but we are watching that closely. Our primary concern is our patients, but of course we do not want the healthcare providers to become ill and need to be quarantined. We are being very cognizant of that and are just trying to work together as a team to help this.

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