Telehealth in the era of COVID-19: Concerns for patients with cancer, heart disease
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Many physicians are now at the front lines of the COVID-19 pandemic. Those who do not have direct COVID-19 roles, including those in cardio-oncology, are trying to maintain normality in medicine as much as possible amid the chaos.
We continue educating medical students and trainees, performing and writing research papers and articles, and taking care of patients. But the system is much different from what we are used to.
We now have telehealth.
According to the American Academy of Family Physicians, telehealth is the practice of medicine using technology to deliver care at a distance. This means that a physician in one location could use a telecommunications infrastructure like a mobile phone or computer to deliver care to a patient at a distant site.
Telehealth in COVID era
In the United States, telehealth was initially reserved for patient care in rural areas with limited in-person physician availability. However, with the COVID-19 outbreak and to facilitate the social distancing recommendations, Medicare began to cover routine office visits via telehealth. Most hospitals have therefore switched outpatient care to telehealth. Furthermore, in the context of the COVID pandemic, telehealth has been promoted by major public health organizations such as WHO and CDC as the standard of care in place of routine office visits.
Telehealth in the era of COVID presents an example of the complexity of risk-benefit decision-making that we make every day. We have to decide which patients to see urgently amid the contagion risk and which can be deferred. Similarly, we need to decide which tests can wait and for how long. This is a particularly acute dilemma for patients with cancer and heart disease.
High-risk population
About 1.8 million people will be diagnosed with cancer in the U.S. in 2020, 5% of whom have elevated risk for heart disease, according to estimates from the American Cancer Society. Unfortunately, this same population — our clinic patients with heart disease and cancer — are also at highest risk for infection, complications and death from COVID-19 due to their cancer, heart disease or a combination of both.
Recent data from China indicate that patients with COVID-19 and a history of cancer were nearly five times more likely to develop severe disease as defined by ICU level of care or death (39% vs. 8%) compared with those without cancer history. Furthermore, 75% of those who had received chemotherapy recently developed severe infection compared with 43% among those without recent chemotherapy.
Telehealth concerns
The safety from COVID-19 of our immunocompromised patients is paramount and the decision to reduce in-person clinic visits is undoubtedly appropriate for the circumstances, there are some concerns regarding possible disruptions and complications that could result from the practice of telehealth in our cardio-oncology patients.
Foremost is the concern for delayed treatment. For our patients with cancer, individualized decisions are being made to postpone nonurgent chemotherapy, elective surgeries and even some radiation therapies as a result of COVID-19. Similarly, from a heart disease standpoint, we have deferred some basic cardiac procedures such as ECGs, echocardiograms, stress tests and even simple blood draws (for cardiac biomarkers, renal function and electrolytes), which would usually inform us regarding each patient’s cardiac condition to help tailor cardiac care during and after cancer treatment. These issues present a particular challenge for diagnosis and management of new high-risk patient referrals to cardio-oncology.
Downstream effects
As we try to balance patient care and make treatment and procedural interruptions for COVID-19, we should be concerned about possible non-COVID downstream negative effects, including morbidity and mortality caused by delays in diagnosis and treatment of these patients with heart disease and cancer. In the cardio-oncology population, timing is crucial in the identification and treatment of patients with potential cardiotoxicity.
There are also limitations on decision-making with telehealth. The best we can do with telehealth is to visualize a patient by video — which not all patients have the technological know-how to do, least of all our underserved/minority population. A telephone visit that most patients can afford is even less ideal since we can only rely on voice information.
Either way, we cannot touch, feel or accurately examine for signs of heart disease or HF. The resulting clinical decision-making process is therefore undeniably flawed, particularly in such a high-risk population of cardio-oncology patients.
Numerous changes
To combat some of these concerns as much as possible, we are asking our patients to measure and record their BP, heart rates, weights and oxygen saturations at home, and provide these numbers to us during the televisit.
Even then, some patients are still limited in their ability to provide these measurements due to lack of funds for the electronic gadgets, limitations in technological know-how, and/or lack of social support to help make this possible. Most of these limitations are especially true for our older patients who also happen to be our most vulnerable.
The changes to treatment and surveillance schedules are also a source of great anxiety to many patients. Open, compassionate and honest communications about these concerns are important in addressing difficult treatment decisions and potential delays in care.
Furthermore, we cannot comfort our patients in the same way. There is a distant dynamic in trying to build a new patient-physician relationship through a phone or video call.
And for the rest of our patients, we have asked them to postpone their visits — and therefore their health care — for the next 2 to 4 months until after the outbreak. This will create a backlog of patients for clinic visits, procedures, surgeries and treatments that will need to be addressed later when life is back to normal after COVID-19.
Winning the battle
Finally, there is the question of what could happen to those who develop significant oncologic problems such as disease progression and/or cardiac complications such as HF in the interim. Some will likely end up in the emergency room amid the COVID-19 excitement. They then run the risk of contracting the infection despite their practiced social distancing at home.
Others will deal with these complications of treatment delays later, after the COVID-19 hustle and bustle. By then, hopefully, it will not be too late to treat them because that would mean in some twisted way that COVID-19 had won, and the toll of COVID-19 would extend well beyond the number of people who tested positive. And after all this raging battle, we cannot let that happen. Not to our patients with cancer, whether they have heart disease or not.
References:
- American Academy of Family Physicians. www.aafp.org/about/policies/all/telemedicine.html. Accessed June 1, 2020.
- American Cancer Society. www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2020/cancer-facts-and-figures-2020.pdf. Accessed June 1, 2020.
- Cardinale D, et al. Circulation. 2015;doi:10.1161/CIRCULATIONAHA.114.013777.
- Grasselli G, et al. JAMA. 2020;doi:10.1001/jama.2020.5394.
- Liang W, et al. Lancet Oncol. 2020;doi:10.1016/S1470-2045(20)30096-6.
- Marron JM, et al. J Clin Oncol. 2020;doi:10.1200/JCO.20.00960.
For more information:
Tochi M. Okwuosa, DO, is associate professor of medicine and cardiology and director of the Cardio-Oncology Program at Rush University Medical Center. She can be reached at tokwuosa@rush.edu.
Nausheen Akhter, MD, is assistant professor in the division of cardiology at Northwestern University Feinberg School of Medicine.
Jeanne DeCara, MD, is professor of medicine and director of the Cardio-Oncology Program at University of Chicago Medical Center.
Chris P. Gans, MD, is assistant professor of clinical medicine at director of the Onco-Cardiology Program at University of Illinois.
Javier Gomez-Valencia, MD, MS, is director of the Stress Laboratory, Nuclear Cardiology and Cardiac Station at Cook County/Stroger Hospital.
Haseeb Ilias Basha, MD, is assistant professor in the division of cardiovascular medicine at Loyola University.
Sunil Pauwaa, MD, is a cardiologist at University of Illinois.
Amit Pursnani, MD, is a cardiologist in the division of cardiology at Northshore University Health System.
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