Oncology Professionals Look Back and Ahead at Cancer Care After A Year of COVID-19

Reflecting on the impact of the COVID-19 pandemic, a panel of oncology professionals at the Association of Community Cancer Centers’ (ACCC) 47th Annual Meeting and Cancer Center Business Summit discussed the permanent paradigm shifts in oncology and how they responded, and continue to respond, to the crisis.¹

“COVID-19 has done more to drive the expansion of digital healthcare and its transformation than any other agent of change that I can think of in recent [memory] or long ago past,” Leigh Boehmer, PharmD, BCOP, said at the start of the discussion. Boehmer, Medical Director of Education with ACCC, moderated the panel of 6 oncology professionals from smaller practices to major healthcare groups who all agreed that the increased role of telehealth is a paradigm shift, among many other changes impacting practices within the past year.

The group also looked back at the responses from the early days of the pandemic that led to hard decisions, but also necessary and creative solutions that they hope will carry over after the pandemic. Furthermore, the group looked ahead at vaccination efforts for patients with cancer while addressing the ongoing problem of screening backlogs.

Permanent Paradigm Shifts

According to the panelists, telemedicine and telehealth allowed practices to not just communicate with patients they could not see in person, but also helped them monitor their patients’ health outside of the clinic. By providing patients with devices that gave them access to their doctors resources they were also able to readily input treatment data that practices would not have had previously, like oxygen levels and other vitals, because there was not a need for these devices at the patients home prior to the pandemic. Moreover, telehealth quickened the pace of survivorship checkups and check-ins with high-risk patients.

At the Mount Sinai Health System in New York City, only 3 telehealth visits were conducted in January 2020, and 5 in February 2020. By April of 2020, 2330 video visits were conducted along with 829 consultations over the phone. In December of 2020, 1143 video visits and 288 phone consultations were conducted, showing the consistency of telemedicine through the start of lockdowns in March to now. Similar spikes were seen by the other oncologists at their practices, and with such huge increases also came a need to build or expand their telehealth infrastructures, which became a vital part of funding from the federal government. The Federal Communications Commission awarded the Ichan School of Medicine $923,487 for their COVID-19 telehealth program to provide devices to patients both inside and outside of the clinic.1 However, funding and infrastructure was easier to come by in the cases of larger health systems that could adapt to the needs of the pandemic quicker, especially in urban areas like New York City.

“My practice is a much smaller practice…[it covers a] large geographic area with a lot of diversity, from a very high socioeconomic level of patient population all the way to patients not able to afford any technical devices,” explained panelist Sibel Blau, MD, medical oncologist and medical director of the independent Northwest Medical Specialties practice in the pacific northwest Tacoma, Washington area.

Blau explained that in order to continue telehealth visits in their area, they had to build the system itself and assign coordinators that would visit patients and teach them how to use the device or set up a connection in some cases. She credits family members and caregivers of patients for “saving them and us” at the start of the pandemic by teaching the patients how to use the device, in some cases using it for them, and helping to build the system they have running now. A system she says that is hard to believe they didn’t have before.

Adaptation and Communication Through COVID-19 Changes

Although telehealth helped to account for survivorship check-ins and monitoring patients undergoing treatment outside the clinic, it couldn’t make up for surgeries. One of the hurdles with many cancer surgeries is that they are considered elective; therefore, when COVID-19 case counts would get too high these treatments had to be delayed to avoid possible infection. Not only did this lead to further complications with patients when they were allowed back in, but surgeons did not have work during the early months of the pandemic in March and April.

“What we did with that group of physicians was during the reassignment, because we all had to go to the intensive care unit and take care of COVID-positive patients, we would reassign the surgeons to these units to take care of COVID patients,” Adam Riker, MD, FSSO, FACS chairman of oncology for Luminous Health in Annapolis, Maryland, described. “We would compensate them for that as a way to offset some of the cost for not being able to produce revenue from the system.”

Riker added that surgeons had to prioritize which patients could wait out surgery until it was safer to come to the hospital and which still needed to be done. Assigning these tiers for patients was aided by guidelines from institutions like the Society of Surgical Oncology, but in some cases has altered the treatment of patients altogether. For instance, patients with breast cancer who had a small area of ductal carcinoma in situ would start on hormonal therapy for several months to continue treatment but wait out the worst of the COVID-19 crisis before coming back in for surgery.

Continuously shifting these responsibilities among oncology staff did result in confusing communication that in many cases has now been settled by a new standard of continuous communication, and resources archived for them. For example, Mary Miller, MSN, RN-BC, OCN, the inpatient oncology manager at the Franciscan Health Cancer Center in Indianapolis, highlighted her shifts to constant video meetings with staff that were recorded and distributed to other teams through the hospital that may not have had as much consistent communication.

“One of the big lessons that I think we learned from this crisis is that we can be problem solvers, and we can do a lot,” added Luis Isola, MD, director of Cancer Clinical Programs for the Mount Sinai Health System, when discussing the leadership and versatility of oncology meeting demands of the pandemic. “In the middle of the crisis, people would sit down and, in a few hours, figure out how to build 15 beds in (another) building, and just do it the next day. In regular times, it would take 2 years, 17 committees and 20 different discussions, and in the end would have never gotten done.”

Catching Up on Screenings While Vaccinations Are Underway

The National Comprehensive Cancer Network (NCCN) released guidelines earlier this year for patients with cancer going to get their COVID-19 vaccine in relation to the timing of their treatment. In most instances, regardless of disease type, patients were recommended to get the vaccine when available. Exceptions included patients on any hematopoietic cell transplantation/cellular therapy who are recommended to wait at least 3 months post therapy, patients with hematologic malignancies on intensive cytotoxic chemotherapy who should delay getting the vaccine until recovery of absolute neutrophil counts, and any patients with solid tumors receiving major surgery should have a few days in between their surgery and receiving the vaccine.²

The vaccination effort is important to making sure patients can return to the clinic safely and oncologists and their staff will also be safe to visit with patients. Yet as the vaccination effort ramps up, a crucial problem to address is the delay in routine cancer screenings. At the heights of the pandemic, patients’ screenings were put off to avoid infection but, in many cases, patients never came back to get them, due to scheduling and fears of infection. The panelists discussed cases they had seen of younger patients coming in with later stages of ovarian cancer that normally would have been caught with screening. Isola remarked that robust data on the impact that delayed and missed screenings would have on patient outcomes will not be seen for another 2 years.¹

However, recent studies have shown that there is a significant number of delayed screenings for all cancer types. Forty-three percent of patients missed their routine preventive appointments because of COVID-19; by July 2020, the Epic Health Research Network released data that while other cancer screenings had begun to increase again, they were still 29% and 36% below previous averages for cervical and colorectal cancer, respectively. Overall, screenings for breast, colon, lung, and prostate cancer dropped by 85%, 75%, 56%, and 74%, respectively, through the pandemic, according to collected billing data.³

According to Jody Pelusi, PhD, FNP, AOCNP, an oncology nurse practitioner at the Honor Health Research Institute, she believes this is an opportunity for oncologists and larger hospital systems to work with primary care colleagues and community systems.1 These groups with more direct and consistent access to patients can help them catch up on mammograms, colonoscopies, and other routine screenings without having to wait for treatment. Moreover, they need to help patients understand that it’s safe to go back in and not to continue the delays where possible. Making sure they’re caught up will be crucial to ensuring worse outcomes are not the norm for oncologists to deal with moving forward. Moreover, the panelists echoed that efforts to communicate with these patients in fast and direct ways was something all practices must consider. In one instance, Boehemer described the creation of quick 2-minute videos showing the clinics social-distancing measures and letting them know most patients will not be in the waiting room due to telehealth visits and social distancing efforts.

“We're seeing some very neglected bad cases [that are] usually very fast, rapidly growing tumors. And they are going to, of course, show up now,” concluded Blau. “There is a big group of patients out there still sitting at home and not [coming back because of their fear] that are going to affect the healthcare system in the years to come.”

_References:

_{1. Isola L, Boehmer L, Riker A, et al. Cancer Care in the COVID-19 Era. Presented at: ACCC 47th Annual Meeting and Cancer Center Business Summit; March 1-3, 2021; Virtual. https://bit.ly/38gKNol}

_{2. National Comprehensive Cancer Network. Cancer and COVID-19 Vaccination (Version 1.0). Accessed March 4, 2021. https://www.nccn.org/covid-19/pdf/COVID-19_Vaccination_Guidance_V1.0.pdf3.}

_{3. Mitchell EP. Declines in Cancer Screening During COVID-19 Pandemic. J Natl Med Assoc. 2020;112(6):563-564. doi:10.1016/j.jnma.2020.12.004}