Cancer care after COVID-19

“Sweet are the uses of adversity.”

– William Shakespeare

In his excellent editorial in April, Derek Raghavan, MD, PhD, commented that it was unusual for us to cover the same subject in successive editions of HemOnc Today.

I am breaking that “rule” again, as the ongoing COVID-19 pandemic continues to dominate our professional and personal lives and impact the care of our patients.

As I write this in late April, we have seen the devastating toll of the coronavirus in New York, which mercifully now appears to be past the peak in terms of new cases and deaths. Similar events are playing out in many major cities across the United States and around the world.

Many cities and states so far have avoided these awful numbers of cases and deaths, possibly because they had more lead time to introduce public health measures that have reduced the spread of the virus.

In many respects, the media coverage of events in New York and many Western European cities has a “different world” feel for me, based in North Texas.

For example, on April 20, the number of confirmed COVID-19 cases in Dallas County was 2,428, with 60 deaths.

This, of course, is too many, but so far, the emergency room and ICU scenes that have been so distressing on TV screens in recent weeks have not been seen here, and there is now cautious optimism that the curve has been flattened. If true, this will allow us to restore some services soon, although there is increasing recognition that the tail on the COVID-19 curve likely will be long, and that we can anticipate continued coronavirus cases at least through the spring and summer.

Transformation in care

As we and others move from preparedness for the coronavirus surge to restoration of our full range of cancer services in the coming weeks, perhaps the only certainty is that the new normal will be different.

Many of the challenges of managing patients with COVID-19 will be with us for months to come, and we will need to adjust practice, workflows, and probably clinic and hospital space to handle them. Some of the changes forced upon us during the pandemic have given us new insights into what’s possible and have positioned us to accelerate the pace of cancer care transformation.

The rapid adoption of remote care through telehealth platforms probably is the most apparent and most widely described change prompted by the pandemic.

Although there have been strong proponents of telehealth platforms for oncology for many years, uptake of these services has been poor. This has been attributed partly to the lack of reliable software platforms, but it is more likely that unfamiliarity or doubts about the process of remote consults — plus some billing and licensure issues — have been bigger hurdles to widespread adoption of virtual visits.

That hypothesis largely has been confirmed. Most large cancer centers have been able to use existing technology against a background of relaxed billing and regulatory requirements, plus a willingness of both providers and patients to consider virtual visits as a safer alternative to in-person visits with the risk for exposure to the coronavirus.

The results have been extraordinary. Many centers have reported transitioning 80% to 90% of their clinic visits to virtual platforms, with high levels of satisfaction among patients and providers. This has been true for new patient consults, as well as second opinion and follow-up visits.

There is widespread acceptance that telehealth is now part of our long-term future. In addition to the convenience and patient-centered nature of this platform for clinic visits, it will enhance patient convenience in other ways.

As an example, we are already seeing changing patterns in our infusion centers. Treatments that typically have been coupled with a provider visit and given at our main campus are now being given at regional sites — more convenient for the patient, who now has no reason to travel into the city for an in-person visit.

Broader implications

On a broader scale, this also provides opportunities for cancer centers to extend care beyond traditional geographies, especially if the relaxation in licensure requirements remains or is expanded. There will be long-term implications for our clinic space needs and staffing levels, template design, and advanced practice provider workflows.

Like many other centers, we have been able to work with clinical trial sponsors to gain acceptance of remote visits for clinical trials. Hopefully, the willingness of sponsors and regulatory authorities to accept these visits will extend beyond the pandemic, giving greater access to clinical trials — especially for those in underserved rural and frontier locations where distance is a barrier to participation.

The changes to remote work go beyond telehealth.

From an operational perspective, many of our administrative and clinical trials staff have been required to transition to working from home. Again, the imperative to transition quickly has resulted in rapid acceptance of this model by our staff, with maintained productivity.

It will be interesting to see the impact on staff engagement over time. Clearly, if the early success is maintained, this also may set a new norm. We will need to ensure adequate supervision of home-based staff, but potential benefits are significant and include reduced space requirements on campus.

The pandemic also may affect our patients’ future perceptions and preferences regarding urgent and emergency care.

Experience from our own center plus recently published data show that patients themselves often are the primary determinant of seeking care in EDs or in inpatient settings.

As some centers already have reported, avoidance of the emergency room and of inpatient admission have been key strategies to protect patients and staff during the pandemic. Many centers have augmented or established their acute care capabilities.

As our patients become familiar with these possible alternatives to the ED or hospital, we likely will need to deploy more acute and palliative care services, as well as hospital at-home programs. All of these are emerging already, of course, but the growth rate likely will increase.

A new standard

Beyond changes in patient care, the rapid increase in the use of virtual meeting platforms likely will not be reversed completely.

It will be particularly interesting to see how the virtual format of this year’s ASCO Annual Meeting is received. If this proves to be a viable medium for a very large-scale meeting, the influence on reporting of research findings and professional education could be profound.

This is not just because of the convenience of desktop access — not necessarily a positive trend in my opinion, as it can’t substitute fully for an in-person meeting — but because of potential qualitative effects of online vs. live presentation.

Nuances of language and lower ability to raise important questions or concerns about data in a real-time context could diminish the value of presentations. Recent data regarding the use of positive language while presenting negative trial results underline the importance of immediacy in these interactions.

The list of potential transformative changes to our practice is long. We will emerge from the pandemic with a different landscape of care that probably will become our new standard.

In addition to observing the impact of these changes, we also will need robust data to track the outcomes of patients who have been screened, diagnosed, treated or entered survivorship during the COVID-19 outbreak.

The impact of diagnostic and treatment delays, changes to therapy schedules, accrual to clinical trials, and monitoring and management of acute issues all will provide vital information about optimal care of our patients, not only during a future pandemic but in our “new normal” landscape.

Many of our patients have suffered even more than usual during this period of adversity. In the spirit of Shakespeare’s words, we owe it to them and to all victims of COVID-19 to learn from this experience and do better.

References:

Di Maio M, et al. JAMA Oncol. 2020;doi:10.1001/jamaoncol.2020.0475.

Raghavan D, et al. JCO Oncol Pract. 2020;doi:10.1200/OP.20.00225.

Schrag D, et al. JAMA. 2020;doi:10.1001/jama.2020.6236.

Zibelli A, et al. JCO Oncol Pract. 2020;doi:10.1200/JOP.19.00518.

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.