Systems Approach to Oncology Needed to Implement Lessons Learned from COVID-19

Benjamin O. Anderson, MD, FACS

The impact of the COVID-19 pandemic has blanketed the health care system. For clinicians treating patients with cancer, there have been unique challenges to overcome as well as unexpected revelations that transform the field in the years to come.

During a Targeted Oncology webinar “Lessons Learned in Pathology and Oncology from the COVID-19 Pandemic,” moderator Dan Milner, MD, MSc, MBA, chief medical officer, American Society for Clinical Pathology, led a panel discussion involving an oncologist, pathologist, surgeon, and radiation oncologist around their different, but connected experiences during the pandemic.

Among the panelists was Benjamin O. Anderson, MD, FACS, consultant, Cancer Control, World Health Organization (WHO), chair and director, Breast Health Global Initiative (BHGI), full member, Fred Hutchinson Cancer Research Center, and professor of surgery and global health medicine, University of Washington, who believes that the lessons from the pandemic unmasked an existing issue with the United States healthc are system.

“If I'm in a really good system, and I think I do practice in a really good system in Seattle, it actually shouldn't matter which doctor the patient sees. I think we're going to get more of that systems thinking and less of the 1 doctor at a time,” Anderson said.

Part of improving the United States health care system is understanding that different patient populations have different resources and coming up with a method that works for all groups. According to Anderson, this is a truth that was greatly highlighted when COVID-19 first emerged.

In an interview with Targeted Oncology following the webinar, Anderson discussed lessons from COVID-19 in further detail.

TARGETED ONCOLOGY: During the webinar, what were the lessons learned that stood out to you the most?

Anderson: The lessons learned are related to how a huge health crisis like COVID, tests the parts of our health care delivery system that don't necessarily get tested all that often. That's provided an opportunity for us to examine what we do. During the discussion, there were a series of examples of how practices have changed, because of COVID, some of which involved going to electronic work and having fewer physical interventions. But I think that we're in a period where we'll be able to stand back and sort out what is it in our health care system that does need to be changed.

If you think about it, health care in the United States, we spend 18% of our GDP on health care, which is not a sustainable level of investment. It’s also clear that we don't get our money's worth out of that. There are ineffective ways in which those funds are spent, because if you look at other countries, there are these huge gaps in how much we're spending. I think that the efficiencies that we're going to learn through COVID and our ability to change as we recognize the old systems weren't so good, is going to be big.

How do you envision these lessons impacting oncology in the United States after the pandemic?

I think that we're going to be doing more work within remote settings. We use the term patient centric. That means, the patient's in the middle, it's as Gralow mentioned, an example of being able to have a telemedicine visit with a patient in hospice who is in their last weeks of life, and what a plus that was for the patient and for the provider. In the past, that just wasn't possible because our health care system was too rigid in terms of what it permits and what it does not permit. I think 5 to 10 years from now, we're going to see changes that are going to be meaningful and real.

How do see the multidisciplinary aspect of oncology care evolving considering the impact of the pandemic?

As our [webinar] discussion illuminated, cancer, in particular, is a multidisciplinary field. So, the traditional way in which we think of health care, is that a patient tries to find who's the best doctor to do this based on who has the best reviews and who their friends and colleagues say is best. That thinking of 1 doctor at a time is really being replaced by systems. If I'm in a really good system, and I think I do practice in a really good system in Seattle, it actually shouldn't matter which doctor the patient sees. I think we're going to get more of that systems thinking and less of the 1 doctor at a time. Then cancer forces that because surgery is only helpful when it's followed by appropriate radiotherapy. It's the drug therapy that decreases metastatic disease and saves lives. We are compelled to think collectively about how to do that, and I think we're going to see much more of that because now we've had practice at it.

Being a physician with a worldwide view of the COVID-19 pandemic, how would you compare the experience of oncology clinicians in the United States to clinicians on an international scale?

We got started with global health care in our group back in the early 2000s. Our program, the Breast Health Global Initiative developed this concept of resource stratified guidelines and how to implement them and how do we build systems when we don't have all the tools in place. There's very much in doing global work. There is a back and forth between seeing what do we do in the high-income environment as well as in the limited-resource environment.

What I have done is I look in the environment and ask myself, what would I do if I was back in Seattle? How would I adapt to this? I think that back and forth is a key component of this. I'm now working for the World Health Organization, and what we recently launched in March was the Global Breast Cancer Initiative. The whole thesis of the Global Breast Cancer Initiative is to translate what we do in high-income settings where we have been very successful. Breast cancer mortality has dropped by 40% between the 1980s and the present time in the US and in Western Europe, how can we recreate that in a limited-resource environment. It causes us to dissect out the pieces of our own tools to apply them. I think it's a full circle thing, because we're going to be applying these in low- and middle-income countries.

We often mention that the best health care is in the United States, but, that's true only for a subset of our population that has all the access. There’s a large proportion of the United States that doesn't get those services, and it breaks down economically and by racial lines. I think we're going to have the opportunity to apply this limited-resource thinking to meet the needs of our communities that are rural, or that have more obstacles to coming in for care. I remain optimistic that those who have been in underserved communities will be doing better 10 years from now because of these experiences.

What is your takeaway message on molding oncology care post-COVID?

I think that we have to collectively examine the American health care delivery system and seriously ask the questions of how can we do better without just spending. How can we organize in ways that make our system effective? That is really important. I think at the same time, one of the discussion points that came out had to do with health care providers, that the pandemic has been incredibly difficult for health care providers that are in the middle of it, trying to do their work in the best way that we can. For those of us that are older and grew up in training, the thinking was more along the lines of you’re the doctor and you can tough it out. I think nurses were the same way. We have to think in a more thoughtful way about sustainability of our health care workforce to make sure that we are asking the workforce to do things that not only they are willing to do but can continue to do over time. I’m sorry to say that we're seeing attrition in the workforce, because it's too hard and we're asking too much. It is time to reevaluate how to do this. We also have to do it in ways that are not punitive to the health care workforce.