When there are (almost) no data
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I am writing this on March 18, as the reality of the COVID-19 pandemic begins to hit home.
Nonessential staff are now working remotely, and the research and administrative areas of our cancer center have taken on a “ghost town” feel.
At the entrance to our cancer center lobby, we have a screening process for all patients and (limited) family members, which seems to be working very effectively so far.
Our patients have been highly appreciative and cooperative, and our front-line staff — as usual — have been doing a wonderful job with caution and reassurance.
Fortunately, rescheduling nonessential visits and telephone symptom screening on the day prior to appointments have reduced the volume of patients overall, although our infusion center remains busy, ensuring that planned treatments remain on schedule.
What follows is my impression of how this situation is playing out at our cancer center, which I am sure is similar to many others.
I do not intend to share new insights — I’m not sure I have any — but simply to relate some of the issues we are addressing as the bigger-picture public health interventions begin to take effect.
A new reality
Our leadership and operational teams are holding daily huddles to evaluate our cancer center screening, triage and management policies. We also are in daily meetings with our larger system to stay aligned and consistent, and to share knowledge and best practices as these emerge.
This is, of course, a very fluid situation, and we are having to adjust and reevaluate daily.
Today is turning out to be typical of this new reality. We are receiving calls about everything from telemedicine options to IT support for tumor boards, from supplies of personal protective equipment to signage to COVID-19 testing.
These seemingly random — but very reasonable — questions are making our heads spin, but during a pause in email and text traffic, here are a few of my own thoughts about the pandemic and our response:
There are almost no data.
This probably is the most worrisome aspect of our response planning. In the past couple days, we have looked for data regarding issues as basic as the value of temperature screening vs., or in addition to, symptom screening at our front door; the degree to which immunosuppressed patients’ risk is elevated; the requirement for personal protective equipment for our staff; which of our patients really need testing; and many other issues.
Not surprisingly, there’s not much out there — a reflection of the rapid emergence of the virus and the limited testing to date.
As oncology professionals, whose practice is based on evidence and available literature, this is in many ways the most unsettling aspect of the current situation.
Fortunately, more resources are becoming available through our professional organizations — including ASCO, ASH and National Comprehensive Cancer Network — as well as venues for web-based interactions with other cancer centers and one-on-one communication with colleagues.
My impression is that the approaches emerging, albeit independently, from many of our centers are remarkably similar. This is reassuring and not surprising. In the absence of a strong evidence base, first principles and common sense should prevail.
We are mostly basing our strategies on the assumption that patients with cancer are more susceptible to COVID-19 and have a poorer prognosis if they are infected by the virus. Limited data from China support this assumption, but we have a lot more to learn about optimal strategies for screening and treatment.
Virtual meetings are necessary but not like the real thing.
As we extend social distancing and have limited our meetings to a maximum of five people, virtual meetings have taken over.
I’m starting to learn the vocabulary of these meetings — phrases like “Who just joined?” or “Can everyone mute their line if they’re not speaking?” or “I’m sorry, I was on mute.”
These platforms definitely provide a convenient venue for maintaining contact. On the other hand, it’s just not the same as meeting in person. Missing out on nonverbal cues, individuals tending to speak at the same time and unreliable connections all reduce the spontaneity of these get-togethers. In difficult times, this is a great way to communicate, but I’m already looking forward to when we can all get around a table again.
Social media is a great resource.
Twitter has directed me to information I otherwise would not have found, and it has been a good opportunity for accessing information from trusted sources.
Difficult times bring out the best and the worst in people.
It has been heartwarming and humbling to see how friends and colleagues across our center have worked together to adapt to a rapidly changing situation, make sure patient care does not suffer and go the extra mile to help.
The same is true across our health system and our community. Unfortunately, there are always those who exploit bad situations. I learned today of COVID-19 phishing emails coming to our center — and, I’m sure, to many others. It is so disheartening when dedicated staff are targeted in this way.
Things likely will get more complicated.
If the number of COVID-19-positive patients increases as expected, it will stretch all of our resources.
In addition to potential equipment and supplies limitations, we may experience staffing shortages. We also may face difficult patient care decisions, balancing the need for intensive support against likely prognosis — especially if ICU bed numbers become limited.
We must do what we can to maintain the wellness of our care teams and minimize burnout during the coming weeks. We already are recognizing some stress and burnout among our teams and need to work hard to provide a supportive environment over the next few weeks, as work-life balance expectations may be skewed toward work.
That is easier said than done, but taking care of our staff, being vigilant to signs of burnout, compassion fatigue or simple tiredness, and expressions of thanks and support will be important.
Seeking ‘steady state’
Over the next few weeks, we will gain experience, probably learn from some mistakes and hopefully get to steady state in terms of handling the challenges for our patients in this pandemic.
Data will emerge that will make our planning easier and our decisions more scientifically based.
In the meantime, we should all engage in the great resources already available — including social media platforms — that allow us to describe our experiences, share our newly gained knowledge and best practices, and help protect our patients.
For more information:
John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is associate director for clinical affairs at Harold C. Simmons Comprehensive Cancer Center at UT Southwestern Medical Center. He can be reached at john.sweetenham@utsouthwestern.edu.
Disclosure: Sweetenham reports no relevant financial disclosures.
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