Cancer clinics confident in COVID-19 precautions to protect patients, survivors
Oncology clinics are bracing for the potential effects of another surge in COVID-19 cases on the delivery of cancer care.
Unlike during the initial wave of the pandemic, however, this time the virus is more of a known quantity, one that clinics feel much more confident in handling.
“It’s a different playing field now,” Steven Pergam, MD, MPH, director of infection prevention at Seattle Cancer Alliance and associate professor at Fred Hutchinson Cancer Research Center, told Healio. “It’s a little bit like baseball; the first time you go out on the Little League field, you have no idea what your position is. You don’t know what you’re supposed to do. Right now, I’d say we are playing triple-A ball, if not the major leagues. We’ve been doing this for months now, and we’ve learned a lot from the process.”
This confidence is something clinicians are now able to convey to their patients and cancer survivors when discussing the safety of in-clinic visits.
“It is completely safe to go and see your doctor,” Debra Patt, MD, PhD, MBA, FASCO, executive vice president of policy and strategic initiatives at Texas Oncology, told Healio. “Since March, we’ve implemented about 30 CDC guidelines to screen patients appropriately, limit visitors, keep our clinic volumes low, and make sure everyone is masking and handwashing. I believe my clinic is the safest place to be in the state of Texas.”
Varying degrees of risk
The extent of a cancer survivor’s increased risk for COVID-19 depends on the type of cancer they have, how far out they are from successful treatment and anti-cancer drugs they might be taking as maintenance therapy. According to Andrew M. Evens, DO, MSc, FACP, associate director for clinical services and director of the lymphoma program at Rutgers Cancer Institute, as well as medical director of the oncology service line at RWJBarnabas Health, the term “cancer survivor” can encapsulate a wide range of people and circumstances.
“This could be someone who just finished their aggressive chemotherapy or bone marrow transplant 6 months ago, who still is immunosuppressed, or it could be someone who’s out from definitive treatment multiple years and whose immune system has fully recovered,” Evens told Healio. “If they’re more in the latter category, we don’t think there is an increased susceptibility to COVID-19, but we don’t know for sure because COVID-19 is still a relatively new virus.”
Cancer survivors often must contend with late effects of their treatment. Evens pointed out that it is not known whether COVID-19 might have long-term or delayed effects that could amplify these late cancer treatment-related effects.
“We know there can be acute fatality and pulmonary issues due to COVID-19, but many patients have asymptomatic infection,” Evens said. “What we don’t know is, years down the road, will there be conditions like ‘COVID lung’ or ‘COVID heart’ that manifest? Are cancer survivors, who are already at risk for increased organ dysfunction, going to incur additional risk if they also had COVID? Longer-term effects are something we’ll need to follow closely over time.”
Pergam said it is important for clinicians to talk with cancer survivors about their degree of immunosuppression and risk for COVID-19.
“It’s always an important conversation to have, because different patients have different rates of immune suppression,” he said. “It’s important not just for the clinician’s knowledge, but also for the patients to get an awareness of immunosuppression and how it might affect them.”
Precautions in the clinic
Cancer clinics have gone to great lengths to ensure the safety of patients and survivors amid the pandemic. Evens said his center starts with education, making sure to discuss masks and social distancing with all active patients and cancer survivors. For those who come for an in-person visit, there is pre-visit phone screening and an additional on-site screening that includes a temperature check and COVID-19-relevant questions. The center is cleaned continually, and patient flow is carefully regulated.
“Our areas are deeply cleaned and sanitized, and we try to space out visits a bit more,” he said. “Of course, all of our staff are wearing masks. Also, whether it’s through a phone screening or at the time we’re seeing them, we discuss the opportunity for telemedicine. This might be appealing to cancer survivors, especially if they are not undergoing active chemotherapy.”
Pergam noted that the lessons learned from the first wave of the pandemic continue to be reinforced daily at cancer centers across the country.
“Most centers have continued to have cases, even when there was no surge,” he said. “So, I think that the clinics and centers are very engaged and aware.”
Pergam said his center also has instituted numerous safety precautions, including routine masking, screening of patients who visit the facility and discussions with patients who are scheduled to come in.
“I think we know the triggers, and if we didn’t feel it was safe at any time, we would know how to address it,” he said.
According to David I. Quinn, MD, MBBS, PhD, FRACP, FACP, associate professor of medical oncology and medical director of Norris Cancer Hospital and Clinics at Keck School of Medicine of USC, patients also have become more aware of COVID-19 prevention measures since the initial months of the pandemic.
“We have a group of extremely compliant patients — older patients especially — who are very good at protecting themselves,” he said. “They realize that this thing could kill them, so they are taking steps to protect themselves and, by and large, they are doing it well.”
Lingering fears
Although much has been learned about how to create a safe clinic environment, some cancer survivors struggle with ongoing fears about outpatient doctor’s visits.
In a retrospective study of 6,227,474 Medicare fee-for-service claims, Patt and colleagues found a significant reduction in cancer screenings, biopsies, surgeries, office visits and therapy between March and July compared with the same period last year.
She said the delays in cancer diagnosis have been especially concerning.
“Cancer diagnoses between March and July were down by 30% to 70%, and biopsies, surgeries and other treatments were also down,” she said. “The natural consequence of people trying to avoid preventive care is that cancers are happening that aren’t being diagnosed, and that’s really dangerous,” she said.
Patt said she understands the fears of patients and survivors, but emphasized that for many patients, disrupting cancer treatment is riskier than visiting a clinic during the pandemic.
“When I was rounding in the hospital in March I was a little bit fearful, but I’m not now, even though cases are higher,” she said. “I’m not fearful because we’re incredibly cautious, and the precautions we are taking with implementation of CDC guidelines provide safety.”
Telehealth appointments remain an option for patients and survivors who prefer to avoid the clinic. Evens said although telehealth visits are no longer his center’s primary means of seeing patients, they are still a very important tool during the pandemic.
“Once the pandemic started, all the rules and regulations [around telehealth] were attenuated, meaning it was made easier for the provider to communicate with the patient, including from home,” he said. “We were able to ramp it up quite quickly at our peak in April and May, and in the summer we were up to 70% of all visits conducted by telehealth. We’ve dipped back down to where we are using telehealth a bit more as a safety net, and now we’re at about 15% to 20%. That might change over the next few weeks.”
Safety in the community
Although cancer centers continue to take every precaution to make in-person clinic visits as safe as possible, Pergam noted that physicians are limited in their ability to keep patients safe in their daily lives.
“It’s important to remember that the vast majority of cases are related to people getting infected in their communities,” he said. “So, it’s all about what they’re doing in their daily activities that puts them at risk. We give guidance and protect patients as much as possible with our policies in place, but we can’t police what they do in their home environments and out in public.”
Pergam said cancer survivors should be encouraged to beware of the potential risks in their communities, including public places and even family gatherings. He said when making essential trips to the grocery store or pharmacy, patients with cancer and survivors should seek out store hours designated for vulnerable shoppers. Additionally, he said patients and survivors should speak to their family members about the need for increased caution when spending time together.
“I think it’s really important for people to have conversations with their families and friends about this, even though it’s a hard conversation to have,” he said. “They need to emphasize that if their family and friends want to see them, they need to be masked. We encourage our patients to tell their families the precautions they need to stay safe.”
Pergam recommended that patients adhere to the CDC’s “Six Cs” of COVID-19 prevention, which call for avoiding crowds, close contact with others and continuous exposure; wearing face coverings, such as a mask; and minimizing exposure to group gatherings in enclosed spaces.
“It’s also important that they take care of themselves,” he said. “I encourage them to eat well, exercise and sleep. These are key pieces for everyone.”
‘Cultural headwaters’
In terms of reducing community spread, Quinn pointed out that for members of some communities, adhering to COVID-19 prevention guidelines is culturally complicated. He said for these individuals, large extended families and certain fields of employment may make isolation difficult.
“If you’re a working-class Latino who works construction, you might be in an environment where your co-workers don’t want to wear a mask, and that can be a big problem,” he said. “Then you go home to your family, who are used to getting together as a group of somewhere between 20 and 80 people on the weekends. Then you might go to church, as well. We’re swimming in cultural headwaters there.”
In addition, there is a cultural divide around the idea of masking to protect both the wearer and other people, Quinn said.
“The issue is that mask-wearing got politicized, and it’s still an issue. I cannot believe that,” he said. “I have physicians from other states who call for a chat because they’re being demonized about trying to protect people.”
Monitoring survivors
Evens said regardless of COVID-19, primary care physicians and other providers who see cancer survivors for long-term follow-up should be aware of the potential health risks these patients face.
“It really is more of the same, because we don’t know if COVID-19 will have a long-term impact,” he said. “It may, but I would revert to the overarching recommendation of enhanced surveillance that most cancer survivors need, regardless of COVID.”
Pergam said once COVID-19 vaccines become widely available, clinicians should encourage their patients to get vaccinated.
“We don’t have as much data about patients with cancer as we do about the general population, but I would say to be on the lookout for that kind of information,” he said. “It will be important to start having conversations with people about getting vaccinated once it is available, and to also get vaccinated against influenza.”
Patt said a PCP can play an important role in detecting depression, anxiety or other mental health struggles among cancer survivors, especially given the isolation of the pandemic.
“Particularly for older individuals who live alone, the psychological consequences of the pandemic have been devastating,” she said. “In my own practice, our social workers have launched virtual support groups for patients, so they can interact with others in the same situation. Even for younger individuals, these are important issues. So, I think counseling people on how they can interact with loved ones in a safe way is very important.”
For more information:
Andrew Evens, DO, MSc, FACP, can be reached at ae378@cinj.rutgers.edu.
Debra Patt, MD, PhD, MBA, FASCO, is a member of Healio’s Women in Oncology Peer Perspective Board. She can be reached at debra.patt@usoncology.com.
Steven Pergam, MD, can be reached at spergam@fredhutch.org.
David I. Quinn, MD, MBBS, PhD, FRACP, FACP, can be reached at diquinn@med.usc.edu.
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