Lessons Learned From COVID-19— 1 Year Later

Mark K. Kyei, MD

The pandemic brought about by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has put some aspects of life on hold for over a year now. However, for people living with serious and potentially fatal illnesses, putting life on hold is not an option.

We’re dealing with life and death situations,” said Mark K. Kyei, MD, a medical oncologist at Cleveland Clinic in Ohio, during an interview with Targeted Therapies in Oncology. “We still need to deliver care for patients and we can’t just compromise because of the pandemic.”

As physicians across all specialties scrambled to find ways to deliver care, oncologists had to balance keeping patients safe from infection with delivering care that frequently has toxic treatments.

“As an infectious disease physician, my team and I were constantly learning, adapting, and implementing protocols based on new science and new evidence—basically everything,” Monika Shah, MD, an infectious disease specialist at Memorial Sloan Kettering Cancer Center in New York, New York, said in an email. “We were in constant motion, especially when there was much uncertainty and real fear, not only from our patients but also our work force.”

Continuing Care Through Virtual and Telehealth Appointments

One could argue that some form of telehealth has existed since patients could speak with their doctor by phone, but systems that deliver effective and consistent care by phone or video are only decades old.

According to a report published by the World Health Organization (WHO) in 2010, “Some predict that telemedicine will profoundly transform the delivery of health services in the industrialized world by migrating health care delivery away from hospitals and clinics into homes.”¹

But despite its convenience, telemedicine did not become as popular as many people had hoped—until now. Not only did patients and physicians begin to ask for distance visits once they understood the severity of SARS-CoV-2, but the US Congress passed an act in March 2020 allowing providers to bill Medicare for telehealth appointments during the pandemic.²

The American Society of Clinical Oncology (ASCO) issued a comprehensive guide to cancer care delivery, updated in December 2020, recommending that clinicians identify patients for whom distance medical appointments would be appropriate, such as those not needing in-person examinations or in-person diagnostics.³

“I switched about 50% of my follow-up patients to either telephone visits or video visits,” said Huynh Cao, MD, a medical oncologist at Loma Linda University Health in California. “These were mostly patients who were in remission, though. Patients undergoing treatment that required visits to the clinic could benefit from a hybrid version, however, using phone or video for meetings between active treatments.”

These virtual visits are necessary, but not always ideal. “There’s such a dramatic contrast between in-person and virtual visits,” Kyei said. “I generally prefer to see my patients in the office, talking to them, picking up cues.”

Patients Need Support During Cancer Care

Patients undergoing cancer treatment often need the support of a friend or family member. Oncologists usually encourage patients with a new diagnosis to bring at least 1 person with them for their first visit. But with most facilities banning companions except for hands-on caregivers, this has become particularly challenging for both patient and clinician.

The oncologists at Cleveland Clinic had the policy modified slightly. “In our department, we allowed 1 person, a caregiver or first-degree relative, to accompany [the patient], especially for a new consult,” said Kyei. “Having someone else there, even if that person joins via phone, can help [them] collaborate and corroborate the information, and remember things that we spoke about.”

He also believes that having this extra person is important for patients at follow-up appointments because when they return they often don’t remember what they were told during previous visits. This means that much time is spent reviewing the information.

To address the visitor restrictions at Cancer Treatment Centers of America (CTCA), Ankur Parikh, DO, director of CTCA’s Precision Medicine Program in Philadelphia, Pennsylvania, suggested his patients bring a device to their appointments so they could include a family member or friend through FaceTime or a similar app. And if the patients didn’t have a device, Parikh said that CTCA would help them with a tablet.

“At least they could be part of the conversation and that helps a little bit, although it doesn’t replace having a loved one with you in person.”

Developing Relationships and Trust

Patients must trust their health care teams, particularly while undergoing treatment for a disease such as cancer.

Luckily, I had established relationships with most of my patients [before the pandemic],” said Parikh. This allowed him to have real conversations with his patients, asking about children or work when appropriate, because that connection had been made. But the situation is different with new patients. “To start with a new patient via telemedicine, you don’t get the full story,” he explained. “What you get are screenshots. You don’t always see the patient as you would [in the office].”

In addition, not all patients can participate in virtual visits.4 They may not have a private area to maintain their confidentiality, or they may not have devices or a reliable service for a good connection. This is particularly concerning in certain populations, such as those who are not financially stable or are home insecure.

Procedure and Treatment Delays

In April last year, the CMS issued recommendations regarding treatment priorities for low-, intermediate-, and high-acuity treatments or services.5 However, according to news reports, procedures were still being canceled, including surgeries to remove tumors or more definitive testing.6 Although these are not elective procedures, they were considered nonurgent.

Kyei explained that Cleveland Clinic has a 30-day time-to-treat policy, which they are working on maintaining, but the pandemic has caused some variability. “There were instances where initiating treatment took more time,” he said, “especially for patients who required additional procedures before starting treatment, as nonurgent procedures were temporarily suspended.”

Parikh’s experience was different, as scheduled surgeries at CTCA continued for the most part. “We ended up seeing a lot of patients from outside that probably wouldn’t have come to us in the beginning because they’d have [had] their potential curative surgery locally,” he explained.

Quarantine and Fear Affect In-Person Visits

The slowdown of cancer care is not wholly the result of facilities cutting back on in-person visits or performing fewer procedures. It can be due to the patients themselves being unwilling or unable to see a doctor in person.

According to a study published in JCO Global Oncology, 46.35% of the centers providing cancer care reported that more than 10% of their patients had missed at least 1 session.⁷

Obviously, patients who developed coronavirus disease 2019 (COVID-19) could not attend their appointments, but there were also those who may have been exposed to someone with symptoms and had to wait for test results, explained Parikh. This would mean another 2 weeks before they could come in to the hospital or clinic, adding to the delay in care. And, the more possible exposures, the more delays.

Then there is the issue of seeing patients who received a diagnosis later than they might have done before the pandemic. Those who experience concerning symptoms may decide to wait out of fear of subjecting themselves to infection. “We noticed that people put off screening tests because of the virus,” said Kyei. “When some people had symptoms, they delayed because they wanted to wait until things got better, and things never really got better. They ended up presenting with late symptoms, advanced disease.

“We are trying to find other means and ways to prevent this because COVID-19, the impact, has the potential of basically undoing all the progress [in screening] we’ve been able to [make] in the past,” he added.

Although limited to colon cancer, one possible step to mitigate this concern is to increase the availability and use of the noninvasive fecal immunohistochemical (FIT) test, which looks for occult blood. “But if that test is positive, you will still need a colonoscopy, which brings you back to square one,” Kyei noted.

Vaccines Moving Things Forward

Now that vaccines for COVID-19 are rolling out across the country, where do people with cancer stand? Most, it seems, do want the vaccine. Almost 80% of Parikh’s patients have discussed the vaccine, he said. “Most of my patients are just waiting to be able to get it.” But when they will get it is the bigger question.

Priority for receiving COVID-19 vaccines is decided at the state level, with each state having its own regulations. “In New York State, anyone with cancer or a history of cancer is now eligible for the vaccine,” said Shah. But this is not the case in all states. “At Memorial Sloan Kettering, we prioritize our patients under the state framework, and are rolling it out in a further stratified fashion among our patients, by age and active treatment status.” That being said, the program is subject to vaccine supply, which varies from week to week, so the staff do not know more than a week ahead of time how many people they can vaccinate.

It is not possible to read about the vaccines without reading about their potential adverse effects. Many people report soreness at the injection site, fever, chills, even muscle aches. These symptoms could also be signs of an infection something people with cancer are warned about. This could result in confusion if patients aren’t sure what is causing these symptoms— the vaccine or the start of an infection.

“I told [my patients that] if their fever is mild, about 100 °F or below, then maybe it’s the vaccine,” Cao said. “But if you have a high persistent fever, above 101°F, then please do call us or get help, or go to the ED [emergency department], because it could be something serious.”

Shah agreed. “The main point to counsel a patient about is that the fever and chills associated with the vaccine should be self-limited. Anything prolonged or anything associated with other symptoms, like cough, shortness of breath, or dizziness, for example, requires prompt investigation. Physicians may also need to consider the timing around when the vaccine was given and where in the therapy cycle a patient may be in their treatment plan. If a patient’s white blood cell count is low and they develop a fever, patients should be counseled on what they should be doing in terms of seeking care.”

Solid Tumors Vs Blood Cancers—Any Differences During the Pandemic?

Cancer care during the pandemic is not all that different between oncologists who treat solid tumors and those who treat hematologic malignancies, except when aggressive cancers come in. “Hematological patients tend to have, sometimes, more aggressive disease…so you really don’t have the luxury of just waiting versus someone who may have stable disease, with colon cancer, for example,” Parikh said.

The American Society of Hematology has issued guidance for some types of cancer, such as acute myeloid leukemia (AML), for which they wrote: “Because newly diagnosed AML is considered treatment-emergent in most cases, intensive induction chemotherapy should still be offered for eligible patients (SIDEBAR)…”⁸

Regardless of the type of cancer, decisions must be made on a case-by-case basis, Cao said. “For a patient with CML [chronic myeloid leukemia] on maintenance therapy, and all the numbers look good and the disease has been stable for a long time, then we have a little more wiggle room and we can hold a treatment as long as possible,” he explained. “But for a patient with AML, newly diagnosed AML, and who had COVID, then you have to make that hard decision to go ahead with the induction, because if you wait a week or 2, that patient doesn’t have that week or 2 to wait.”

Shah added that her team learned and knew that the risk of having a more severe and/or prolonged illness with COVID-19 was greater in their patients with hematologic malignancy. Thus, COVID-19 screening prior to new treatment initiation became an early strategy at Memorial Sloan Kettering. “For example, we would not want to [give a] transplant to someone with new COVID-19,” she wrote in an email.

COVID-19 and Oncology Research

The research side of oncology was also affected by the pandemic, both in the lab and clinically. Cao, who oversees a translational lab that focuses on AML treatments, has experienced delays in getting supplies, including the mice his team needs.

For clinical trials, recruitment became a lot more difficult. Participants did not want the extra travel and additional blood draws and other assessments these studies require, said Parikh.

“In some places, almost all clinical trial activity ceased as difficult decisions were made about balancing patient access to critical cancer clinical trials and exposure to COVID-19,” Mark Reeves, MD, PhD, director of the Loma Linda University (LLU) Health Cancer Center, said in an email. “Here at LLU Cancer Center, we kept our trials open for accrual, and made these trials available to patients, but with tremendous care to minimize the risk of COVID-19 exposure. Trial accrual was less here than prior to COVID- 19, but it was still fairly brisk, and it certainly did not come to a halt as it did in many places.”

The delays in clinical trials may come back to haunt us in the future. “We’re not recruiting to the degree as we did [pre-pandemic],” Parikh said, “so that is really impacting the results we are going to get. But we also have to be a little more creative now to structure various trials in the world we are in today.”

Post-COVID-19 Oncology

Many believe there will be a spike in the diagnosis of more advanced cancers as people finally get screened post pandemic but, according to Kyei, there is another post-pandemic concern: treating patients for cancer years after they have had COVID-19. Although the exact numbers are unknown, many people develop post-infection complications, which could become a pre-existing condition that affects cancer treatment down the road.

“Some people will develop permanent lung damage and cardiac injuries, and neurologic symptoms,” Kyei said. These are issues related to some cancer treatments, although usually among older patients. But with younger patients recovering from COVID-19, the issues could affect treatment options in the future.

_References:

_{1. World Health Organization. Applications and services for diverse context. In: Telemedicine: Opportunities and Developments in Member States: Report on the Second Global Survey on eHealth 2009. WHO; 2010:10. Accessed March 4, 2021. https://bit.ly/3rtd6q9}

_{2. Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020. Department of Health and Human Services. March 6, 2020. Accessed March 4, 2021. https://bit.ly/3m2wIQP}

_{3. ASCO Special Report: A Guide to Cancer Care Delivery During the COVID-19 Pandemic. ASCO. Updated December 15, 2020. Accessed March 4, 2021. https://bit.ly/3rGr2NX}

_{4. Broom A, Kenny K, Page A, et al. The paradoxical effects of COVID-19 on cancer care: current context and otential lasting impacts. Clin Cancer Res. 2020;26(22):5809-5813. doi:10.1158/1078-0432.CCR-20-2989}

_{5. Non-emergent, elective medical services, and treatment recommendations. CMS. April 7, 2020. Accessed March 4, 2021. https://go.cms.gov/39mXbn2}

_{6. Stone W. As coronavirus strains hospitals, cancer patients face treatment delays, uncertainty. NPR. April 2, 2020. Accessed March 4, 2021. https://n. pr/3ryUs04}

_{7. Jazieh AR, Akbulut H, Curigliano G, et al; International Research Network on COVID-19 Impact on Cancer Care. Impact of the COVID-19 pandemic on cancer care: a global collaborative study. JCO Glob Oncol. 2020;6:1428-1438. doi:10.1200/GO.20.00351}

_{8. COVID-19 and acute myeloid leukemia: frequently asked questions. American Society of Hematology. Updated January 22, 2021. Accessed March 4, 2021. https://bit.ly/3u7BEXp}