publication date: Nov. 20, 2020
By Alexandria Carolan
This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage is available here.
The United States faces the worst-yet surge of COVID-19, but cancer hospitals have learned to adapt to the pandemic, opting to continue cancer services at an unchanged pace.
“Treatment, surgeries, procedures are still occurring with minimal delays. Worst case, we are triaging who gets treated and who doesn’t,” Howard H. Bailey, Andy and Susan North Professor of Cancer Research, professor of medicine, obstetrics and gynecology, director of University of Wisconsin Carbone Cancer Center and associate dean of oncology at the University of Wisconsin School of Medicine and Public Health, said to The Cancer Letter.
To gauge how cancer hospitals are responding to this new wave of infections, The Cancer Letter posed the following questions to leaders of cancer institutions across the U.S.:
How do you expect this new surge to affect cancer care? What’s your best-case and worst-case scenario?
What have learned over the spring and summer that you’re implementing now? What are some of the tools you have now that you didn’t have during the first wave?
Are you going to be able to provide cancer services? Do you expect patient volume to be as low as it was in the spring?
What are your recommendations to patients, faculty, and staff on how to spend the holidays?
When the crisis first hit in the spring, many U.S. cancer hospitals decided to delay or postpone treatments for cancer patients. When the rate of new infections decreased over the summer, cancer hospitals resumed operations and started to work through the backlog of delayed treatments.
“This time will be different—in the spring the state and the country stopped, and it allowed us to catch our breath, so to speak,” Hannah Hazard-Jenkins, director of West Virginia University Cancer Institute, associate professor, and associate chair of surgery for cancer services at J.W. Ruby Memorial Hospital, said to The Cancer Letter. “We will not have that this time, and it will pose very different challenges moving forward.”
At this writing, 250,000 people in the U.S. have died from the disease caused by SARS-CoV-2. Incidence of COVID-19 continues to rise, with every state reporting exponential spread of the virus.
As a result of delayed diagnoses and cancelled treatments, NCI CISNET modelers predicted that COVID-19 is going to increase cancer mortality in breast and colorectal cancers by about 10,000 deaths. NCI Director Ned Sharpless warned that this likely applies to other cancers as well (The Cancer Letter, June 19, 2020).
“This time, the number of cases we are seeing is much higher, and what drives our decisionmaking is no longer highly dependent on PPE, but on bedspace in the hospital and the availability of key personnel who are contracting the virus through community spread,” Hazard-Jenkins said.
The upcoming holidays are a concern for these hospitals. The Centers for Disease Control and Prevention Nov. 19 urged Americans not to travel for Thanksgiving.
To present the risk of gathering in groups, Georgia Institute of Technology has created a map describing the chances of exposure based on event size and location.
The COVID-19 Event Risk Assessment Planning Tool shows the risk level of attending an event, given the event size and location.
“It’s not your chance of getting infected with COVID. That’s not what the map is showing. It’s just a chance that one or more people there may have been infected with COVID,” Clio Andris, who co-developed the project, said to The Cancer Letter.
According to the map, states in the middle of the country have it worst. If you were to attend an event with 10 people in several counties in the Midwest, there would be a 99% chance that you would encounter at least one infected person.
“More recently, along with North Dakota, South Dakota and Wisconsin had a big surge as well. But before that, we were looking more at Arizona and Florida as having these surges,” said Andris, also assistant professor of city and regional planning and interactive computing at Georgia Tech. “We’re seeing that things are getting worse and worse and worse. And so, back in September, things had gotten a bit better, and the risk was lower. But seeing towards the end of October, things started to get worse. And now, late November, it’s the worst it’s been in a long time.”
Andris said she expects the risk to increase.
“It’s spiraling out of control a bit, it seems, as somebody who’s looking at the data, and not as an expert epidemiologist,” Andris said. “We’re not seeing the behavioral changes that would be needed to really mitigate it from a public health standpoint. We need to rely on the government to create rules and laws that help, because people don’t seem to be taking the initiative on their own.
Leaders of cancer hospitals are heeding these warnings.
“Patients should not gather outside their bubbles during the holidays. They should remain in small family units and follow the recommendations for social distancing,” D. Neil Hayes, scientific director of the University of Tennessee West Institute for Cancer Research and Van Vleet Endowed Professor in Medical Oncology at the University of Tennessee Health Science Center, said to The Cancer Letter.
Howard H. Bailey
Andy and Susan North
Professor of Cancer Research,
Professor of medicine,
obstetrics and gynecology,
Director, University of Wisconsin Carbone Cancer Center;
Associate dean of oncology,
University of Wisconsin School of Medicine and Public Health
It is altering how we “follow” our patients, primarily through remote. Our active cancer (whether newly diagnosed or being treated for advanced disease) patient volumes decreased slightly in the spring, and are slightly reduced now.
The number of patients undergoing chemotherapy is down slightly. Relative to our ongoing surge—best case is the current: Treatment, surgeries, procedures are still occurring with minimal delays. Worst case, we are triaging who gets treated and who doesn’t.
We have had a more rapid switch to remote visits and have limited clinic exposures, and have better COVID testing now than in spring.
We expect to continue cancer services. I expect volumes to be slightly diminished. We are anecdotally noticing, in some disease areas, more new diagnoses through the Emergency Department, rather than primary care—implying patients are waiting until they can’t wait.
For the holidays, limit travel if desiring to meet with family/friends—wear masks throughout, and limit contact. For our profoundly immunocompromised—we are advising against gatherings of any kind.
Physician-in-chief, director of cancer,
Northwell Health Cancer Institute
In some ways, I believe that we are still feeling the effects of the initial wave of COVID-19 infections, so that a new surge will actually be more of a ripple effect—the difference being that we are much better prepared to handle whatever comes our way. Since we have learned a lot, we do not believe that we will need to shut down services to the degree we did in the early stages of the pandemic.
The best case scenario is that we will have a safe and effective vaccine before the end of the year, but it will take some time before they are widely available and distributed. Until then, our most effective weapons against preventing the spread of COVID-19 remain the proper and consistent use of face coverings and PPE, maintaining social distancing, and engaging in proper hand hygiene.
As we prepare for a second COVID-19 wave, we are better equipped to care for these patients. One of the major lessons learned was the need to decrease the flow of traffic in our ambulatory centers to decrease transmission rates, while recognizing the hardships this places on patients and their families.
With the widespread availability, we are judiciously testing our patients for COVID-19. All solid tumor patients are tested prior to their initial chemotherapy and undergo repeat testing based on screening with a symptom checklist. Patients with hematologic malignancies are tested at initiation of therapy then every three weeks.
We were able to continue treating patients with radiation at the start of the pandemic and expect that to remain the same. Patients undergoing radiation do not require testing unless symptomatic or if they have a history of exposure. All patients undergoing surgery require negative testing within 72 hours.
Equally important was the realization that we must take care of our front line workers and prepare for the emotional and psychological toll that a second wave of COVID-19 may cause.
We also learned that a lot could be achieved by the use of telehealth, and this is something that will definitely continue. In addition, we were also able to treat some COVID-19 positive patients with modified chemotherapy regimens as well as radiation. For cancer patients with COVID-19 infection, new treatment protocols coupled with scientific advances and newly approved therapeutics will enable us to deliver even more effective care to these patients.
We plan to continue to treat cancer patients despite a new surge, while doing everything to ensure their safety, but this, of course, will depend on the level of the surge that we experience. We will utilize COVID-contained zones with increased use of testing—and this will include sites for surgery, as well as chemotherapy and radiation, so we don’t anticipate the level of decreases that occurred in the spring.
We have also developed emergency response standard operating procedures to continue to provide cancer clinical trials that may benefit our patients. This will require the use of telehealth and remote consenting procedures. We also need to continue to provide screening procedures, such as mammography and colonoscopy, to avoid the increase in projected cancer deaths that avoidance of screening may lead to.
We encourage all to continue adopting COVID-19 safety precautions with their families, friends and social networks, especially as people prepare to potentially gather indoors during the holiday season. We wish everyone a safe, happy and healthy holiday season.
Michael J. Birrer
University of Arkansas for Medical Sciences;
Director, Winthrop P. Rockefeller Cancer Institute;
Director, Cancer Service Line
The best-case scenario is that the surge does not materialize, or if it does, it’s limited, and our health systems are able to handle it. The worst-case scenario is that it overwhelms the system. In this case, triage and prioritization will become important. In addition, we will enlarge our intensive care beds along with available ventilators. I think, in the end, we will meet all of the challenges of the COVID pandemic
COVID is important, but so is caring for cancer patients. They expect prompt diagnosis, timely effective therapy, including chemotherapy. We have streamlined our screening process and are now allowing visitors, which greatly helps the quality of life for our cancer patients.
We will continue to meet our Arkansas cancer patients’ needs. Our clinics are fully open and our volumes remain strong.
Enjoy family and friends during the holidays—it’s important, but also stay safe. Maintain social distancing, and use masks when you can’t.
John F. Deeken
President, Inova Schar Cancer Institute;
Inova Schar Head and Neck Cancer Program
We have learned so much over the past seven months in how to contend with this pandemic, from patient screening, testing, and triaging patients based on COVID infection severity. We also rapidly pivoted to using telemedicine when possible and appropriate.
In the best-case scenario, we adjust our outpatient clinics and treatments, including chemotherapy and radiation, to enable cancer care to continue despite rising infection rates. We use what we have learned about COVID treatments to do far better than the 16% mortality rate we saw in the spring in cancer patients who become infected with COVID.
In the worst-case scenario, our inpatient hospitals become overwhelmed with COVID patients, our cancer patients again refuse to go to the ER when their medical condition warrants, and cancer screening efforts are again put on hold.
We learned how to protect cancer patients and safely treat them with our comprehensive cancer center policies, including our COVID testing clinic—separating COVID patients from other immunosuppressed patients, testing patients prior to starting chemotherapy, home remote monitoring of cancer patients with COVID who have mild to no symptoms, use of PPE including face shields as well as masks, and providing telemedicine services when appropriate. All of these tools will be put to good use as we enter the difficult season ahead.
We never saw a drop in active cancer patient treatments in the spring—in fact, our volumes grew by 10%. We maintained active treatments, and even kept our clinical trial program fully open. We did see a dip in breast surgery clinic visits in May and June, due to decreased screening studies being done—but that now has more than rebounded.
We rapidly moved toward telemedicine visits, and at one point had about 80% of our clinic visits done via telemedicine. Now, that is about 20%. We expect to see that gradually move toward more telemedicine percentages if the situation significantly worsens.
We learned a great deal in the spring on how to continue cancer care despite COVID, and will continue to refine our processes going into the winter to maintain our patient care. As long as the people in our community continue to safely distance, wear masks, and wash hands frequently, we hope to not see the overwhelming experiences that Seattle and New York City saw early in the pandemic.
Be safe. Wear a mask. Maintain social distances. Follow the guidelines of the CDC as well as the elected and health officials in your state and county. Be especially careful with older family members and anyone with a cancer diagnosis, to get them successfully through this time period until the anti-COVID vaccines become widely available.
Wafik S. El-Deiry
Director, Cancer Center at Brown University;
Director, Joint Program in Cancer Biology,
Brown University and Lifespan Cancer Institute;
Attending physician, hematology/oncology, LCI;
Mencoff Family University Professor,
Associate Dean of oncologic sciences,
Warren Alpert Medical School, Brown University;
American Cancer Society Research Professor
There will be more telemedicine visits. This is mostly to reduce the numbers of patients on site, if they don’t absolutely need to be seen in person. Patients who need to be seen on site will be seen as we consider those situations low risk with current PPE use by both our care team and patients.
There are plans in our state to open up facilities at various sites as our hospitals fill up and additional capacity is needed. There are now some therapy options that could be helpful such as antibody therapies that can be used for the most high risk patients.
This includes a recent emergency use authorization for bamlanivimab and recent guidance from the CDC for the high risk individuals for whom its use is being prioritized. Anything that can prevent worsening of symptoms can help and we didn’t really have these or other capabilities (availability of data with remdesivir or steroids in COVID) months ago.
We intend to continue caring for patients. The patients who need active treatment need to get it. There will continue to be an impact on cancer screening as patients weigh the risks while the pandemic is surging. We have encouraged patients to not put off cancer screening or care and we will do everything possible to facilitate their care. Our clinical trials kept going and enrolling patients through the spring and we expect that to continue as long as staff are available.
During the surge of this pandemic, everyone must use caution in situations where risk is increased. This means avoiding large gatherings, maintaining social distancing, using PPE, and strong consideration of staying home and not traveling or having holidays turn into spreader or superspreader events. If we can all be patient long enough for a vaccine to become available, this period will pass and hopefully later in 2021 more things will be back to normal.
I would like to add that we’ve been actively doing research so we can learn more and develop new approaches to deal with COVID-19. Our first study was just published and made the cover of the Nov. 17, 2020 issue of the journal Oncotarget. This paper culminates several months of intense effort by a very talented multidisciplinary group of collaborators.
We discovered in our preclinical studies that MEK inhibitors as a class have effects that are relevant to COVID-19 and worth testing further. For example multiple MEK inhibitors suppress SARS-CoV-2 infectivity factors, boost natural killer cell killing and attenuate cytokines. We showed that MEK inhibitors reduce a SARS-CoV-2 Pseudovirus infection of human lung and small airway epithelial cells.
We hope to see further effort in clinical trials for example looking at whether MEK inhibitors might add something useful to remdesivir in slowing progression to severe COVID particularly in COVID-positive patients who are hospitalized but don’t require much oxygen or ICU care. There are many clinical trial opportunities and we think with the surge, trials will help us learn more quickly what may be helpful to patients.
In addition, we have a manuscript under review that should appear on the preprint server BioRxiv soon where we tested plasma samples from COVID-positive versus COVID-negative individuals. This analysis from a large panel of cytokines, chemokines and growth factors in a good-sized patient cohort points to macrophage activation syndrome as an important lead in predicting COVID disease severity and which could be helpful in monitoring the effects of therapeutics. We believe this type of collaborative research is very important at this time to complement other efforts in the field to develop therapeutic antibodies and vaccines.
Mark B. Evers
Professor of surgery, Mark McDowell Cancer Foundation Chair,
Lucille P. Markey Cancer Center;
Director, Markey Cancer Center;
Physician-in-chief, Oncology Service
Best case: All operations continue unchecked with continuation of our clinical research, non-urgent surgical cases, and uninterrupted screening services. Also, maintaining visitor accessibility to in- and out-patient care settings and maintaining healthy and productive staffing levels.
Worst case: Restrictions to clinical research, delays to non-urgent procedures and screening services. Removing visitor accessibility to in- and out-patient care settings. Reduction to productive staffing levels due to compromised health conditions.
[What we learned over the spring and summer was to implement] efficient daily screening of patients and staff, limited visitation, mandatory masks, and distancing at all times. In addition, we effectively utilized telehealth services for care when indicated. Currently, there is a better understanding by faculty and staff of the disease and its behavior. All inpatients and all surgical patients are COVID screened. Rapid changes in operations are ready for implementation when indicated.
Even though infection rates are higher in the community, we do not expect volumes of ambulatory visits or surgeries to decrease to spring levels. COVID screening of all surgical patients means that indiscriminate canceling of elective surgeries will not be necessary. Unfortunately, preventative services are likely to be negatively impacted with a rise in COVID-19 numbers.
However, our ability to manage and maintain a safe care environment for all our patients, caregivers, and clinical team will ensure cancer care continues for those with new disease or under active treatment. New telehealth services will allow providers to manage surveillance and long-term survivors until the pandemic subsides.
[For the holidays, practice] distancing, small groups, wear masks, and don’t travel unless absolutely necessary.
D. Neil Hayes
University of Tennessee West Institute for Cancer Research;
Van Vleet Endowed Professor in Medical Oncology,
University of Tennessee Health Science Center
My expectation is as follows:
COVID has impacted our ability to treat patients who normally travel for their care. Usually, we have housing for out-of-town patients, but this is greatly reduced because of restrictions in our ability to supplement costs for traveling patients. This is especially bad for intensive treatments, like radiation, where they need daily treatment, but cannot travel the distance involved, and cannot get local housing.
COVID has hit our ability to treat patients in nursing homes. Nursing homes are fearful of transporting patients back and forth for chemotherapy or radiation because this creates a hole in their bubble. They are worried about such patients bringing in COVID. Nursing home patients are finding it harder to get treatments and are being directed toward more palliative approaches. Many of them are sick, and a hospice decision is reasonable—but it is not what would happen normally.
Many patients are deferring the initial visits to the surgeons or other providers that would have diagnosed the initial cancer, and I think some diagnoses are being delayed.
Once patients are in treatment, COVID is causing some delays in things like routine X-rays and procedures, because of the requirement to get screened before the procedure can occur.
Our clinic closed one day per week, which complicated things for us. This was a money decision, not so much because we were losing money, but because the hospital was.
I think we learned that if we take the common precautions of masks, hand washing, and other proven techniques, the transmission rates in the hospital are not terrible. I am not an expert in this per se, but it does appear that we are not seeing lots of in-house transmission. We have also tried to adapt to all of the issues above to do the best to manage patients.
For the moment, outpatient cancer care remains on track, although hindered as described above. I think we are likely to see some older patients shifted toward simpler treatments or hospice, because of the added burden of cancer. We are likely to see some delays in diagnosis because of patients and provider behaviors. We are likely to see some delays because of slowed services.
Patients should not gather outside their bubbles during the holidays. They should remain in small family units and follow the recommendations for social distancing.
Director, West Virginia University Cancer Institute;
Associate professor, associate chair of surgery,
Cancer Services, J.W. Ruby Memorial Hospital
This surge is different for the WVU Cancer Institute and West Virginia. In the spring, we were driven to act based on minimal understanding of the disease, limited PPE and testing for the disease. The number of COVID cases in our state remained relatively low in the spring.
This time, the number of cases we are seeing is much higher, and what drives our decision-making is no longer highly dependent on PPE, but on bed space in the hospital and the availability of key personnel who are contracting the virus through community spread.
Our best-case scenario is we weather this as well as we did in the spring, without slowing down screening practices and maintaining timely operative interventions. Our worst-case scenario is that our hospitals enter a scenario where we do not have enough bed space to allow our cancer care to proceed according to national guidelines.
This time will be different—in the spring, the state and the country stopped, and it allowed us to catch our breath, so to speak. We will not have that this time, and it will pose very different challenges moving forward.
The lessons of the spring are global— how the disease is spread, what precautions are necessary, maintaining adequate PPE and increasing capacity for testing. We developed mechanisms to mitigate potential exposures such as using telemedicine and we developed algorithms for identifying priorities for operative cases with cancer being highest in schema.
All of these are being implemented again, but with a different bend. We aren’t making decisions based on availability of PPE and testing; we are making them based on bed space from high community spread. Those decisions look a little different, but we have a solid frame of reference based on our spring experience.
There were some definite moves we (and the nation) made in the spring we will try not to repeat and ultimately learn from. We learned the impact of not screening as we are seeing patients present with more advanced disease and the hope is to maintain screening during this surge.
We learned we could do telemedicine but I think more importantly, we learned everyone is not capable of getting care this way. There are portions of our catchment area that do not have broadband at their homes and a portion of our older population are not technologically savvy enough, even if they did have broadband.
So, we learned we need other ways to deliver care and that telemedicine is not quite as successful in some areas of the country. Aside from the above “technical” components of our learning curve, what I was struck with most in the spring was the grace and humility of our cancer community.
Patients acknowledged and accepted deviations of care to keep themselves and others safe. Our staff showed up to work every single day, putting the unknown and fear of catching a deadly virus second to their dedication to their patients. Never once did I hear opposition to any task set before them because they knew the lives of our patients are that important.
Our volume shift in the spring varied on type of treatment received. Our clinic volume certainly dipped, and we moved patients to telephone or telemedicine when possible. As with most of the country, our screening volume went to nothing, and we are seeing the consequences of that now. However, our infusion volume varied, at most, by 15% and most of that was for the non-chemotherapy infusions.
Additionally, our radiation oncology practice maintained and at times exceeded the expected volume. We will provide cancer serves during this surge as we did through the last. My hope is that with this surge, we will not have to halt our screening practices and we will be a little more discriminatory on which patients can do telemedicine and which patients can and need an in-person visit. My plan is our clinical and screening patient volumes will not drop as it did in the spring.
We all must be smart in our choices. In the spring it was easy—the world basically stopped, and everyone abided/adhered to the recommendations of social distancing and masking due to fear and lack of knowledge. It has been a long eight months for our country and the frustrations of isolation and lack of a treatment will become more apparent as we are denied the ability to congregate in large groups. My recommendation is to maintain the bubble established over the last 8 months.
This year, for me, what I am thankful for is different than years past; I am thankful for the ability to celebrate, even though it is different, and I am thankful for the dedication and selfishlessness of every single healthcare worker and hospital/outpatient personnel that has shown up to work since the beginning of the pandemic.
Paul J. Hesketh
Director, Lahey Health Cancer Institute;
Director, Sophia Gordon Cancer Center and Thoracic Oncology,
Lahey Hospital and Medical Center
I am more optimistic than I was when the initial surge occurred in the spring. At that time the complete lack of knowledge about COVID-19, its natural history, most appropriate management strategies and the rapid increase in number of infected patients requiring hospitalization, often with admission to ICUs strained many health systems to the near-breaking point.
We are now much better prepared to deal with a new surge of cases given expanded testing capabilities, adequate PPE supplies, more effective therapeutic capabilities and the development of organizational and administrative structures totally focused on responding to any new challenge.
During the first surge, most non-cancer-related elective surgical and diagnostic procedures were canceled. Cancer surgeries, for the most part, with the exception of some patients with prostate and breast cancer, continued. Cancer screening procedures, such as mammography, CT-lung screening and colonoscopies were shut down.
The potentially negative impact of delayed screening remains to be seen, but is a major concern. We did not experience a major reduction in our cancer infusion volumes, because, again, for most patients, therapy could not be safely postponed. Radiation therapy volumes did go down somewhat, especially for some early stage breast and prostate patients.
The negative emotional and physical toll on our cancer providers cannot be forgotten as we had to re-deploy both physicians, advanced practitioners and nurses from our cancer clinics to the ICU’s and inpatient floors to care for the overwhelming number of COVID-19 patients. In addition, our research mission was negatively affected as we had to temporarily close a number of clinical trials to accrual and postpone the initiation of several new trials.
My best-case scenario is that our ability to deliver timely and effective cancer therapeutic services will be minimally disrupted by the currently developing surge in COVID-19 cases. Best practice measures to create a safe environment for patients and staff (pre therapy COVID-19 testing, pre-visit and on-site patient screening, mandatory mask, hand washing and social distancing measures, expanded telehealth) will allow us to continue to function without major disruption.
We also have plans to continue critical radiographic screening procedures. At Lahey Hospital and Medical Center we have one of the largest CT lung cancer screening programs in the US and we are committed to minimizing the impact of COVID-19 on this life-saving program.
We have been provided greater flexibility by both governmental and commercial regulatory authorities to incorporate telehealth and remote monitoring options into our clinical trials which should allow our essential clinical investigation program to maintain momentum.
My worst-case scenario, which I think is much less likely, is that there will be a rapid increase in the number of COVID-19 cases requiring hospitalization, similar to the volumes noted in the spring which could prove overwhelming. Although better prepared, our hospitals will again be challenged to maintain all essential services for non COVID-19 patients.
This would have the potential to divert resources away from cancer services to care for this critically ill population. So far, although numbers of COVID-19 hospitalized patients are increasing in our Beth Israel Lahey Health system hospitals, lower proportions are requiring ICU admission than during the spring surge. The long-term negative financial impact on our institutions could also prove to be a less immediately visible but ultimately greater threat to our ability to fulfill our clinical and research cancer missions.
We have learned a number of key points during our initial experience with the COVID-19 pandemic which should prove invaluable as we start to deal with a second surge in cases.
The rate of COVID-19 positivity in asymptomatic cancer patients presenting for treatment in our infusion, radiation therapy and diagnostic centers has been very low
The likelihood of staff members practicing appropriate precautions acquiring COVID-19 infection from patients has also been very low
Treatment with chemotherapy and checkpoint inhibitors could be safely delivered during the peak of the first wave without leading to an apparent increase in morbidity or mortality
Markedly expanded telehealth capabilities with an increasing proportion of video as compared to telephone only visits
Much more robust capabilities for COVID-19 testing
Unless there is an overwhelming second surge, I am confident that essential cancer services will continue to be delivered in a safe and timely manner. Patient volumes for those on active treatment should not significantly diminish given the protocols that are now in place to insure patient and provider safety. Please see additional comments made in response to question one.
Clearly it will be a dramatically different year for all of us as we plan our holiday celebrations. My advice includes maintaining strict adherence to good hygiene (mask use, hand washing and social distancing, especially as most activities shift indoors) postponing typical in-person social gatherings, minimizing non-essential travel, and limiting family get-togethers to small numbers of individuals who, for the most part, have all been living in the same household.
The important thing to keep in mind is that current progress in the development of effective therapeutics, and especially vaccines, makes it very likely that our holiday season one year from now will be markedly different.
Roy A. Jensen
Director, The University of Kansas Cancer Center and Kansas Masonic Cancer Research Institute;
William R. Jewell Distinguished Kansas Masonic Professor;
Professor of pathology and laboratory medicine, anatomy and
cell biology, cancer biology and molecular biosciences
Thus far, the new COVID-19 surge has not limited our ability to provide comprehensive cancer care. We continue to operate at full capacity in our treatment and research functions with no plans to limit access to needed services. In order to do so, extra efforts are needed to protect the health and emotional well-being of patients, families, medical providers and staff.
We are expanding all possible resources, improving and streamlining communications, and extending cancer care services to meet patient needs. Examples of this include telehealth and home infusion services, and keeping our staff healthy. In addition, there is added emphasis on educating our community on COVID-19 prevention and safety through our patient advocates.
The best-case scenario is that the safety measures and protocols we have in place continue to be enough to provide uninterrupted patient care. We hope to have enough protective measures such as PPE, and a vaccine for at-risk populations, including cancer patients and medical providers.
The worst-case scenario is that we see a continuance or acceleration of the current curves for new cases and deaths. Limited staffing or bed availability could create a need to triage care based on a series of predetermined algorithms around need and severity.
The oncology workforce could be compromised by staff COVID-19 infections and quarantine requirements, and we could experience PPE and resource shortages, which in turn could then lead to further staffing issues. If cancer care services are limited, this could delay or stop life-saving surgeries, radiation and medical treatments—eventually leading to more cancer deaths due to COVID-19 and cancer.
Transmission and infection of COVID-19 is preventable if people wear face masks and appropriate protective equipment, social distance and wash hands regularly. In the spring/summer we implemented rigorous safety procedures and protocols. We learned how to consent and take care of cancer patients remotely, and with a limited crew physically on-site.
COVID-19 testing is now available to almost everyone who needs to be tested. In March, we were one of the first centers to test patients for COVID-19 before starting chemotherapy—preceding any standard of care guidelines around asymptomatic testing.
We did this via an investigator-initiated trial, which we developed and launched in just nine business days. Our decision to screen patients pre-chemotherapy was based on early reports indicating their increased susceptibility to complications from the virus.
We have adequate PPE and telehealth tools providing the ability for some procedures to be completed close to home, saving the patient a trip and limiting both patient and staff exposure. Since March 29, 2020, a total of 16,813 telehealth appointments have been conducted, representing roughly 13.3% of all appointments with a physician/APP. Most importantly, KU Cancer Center’s health professionals and administrators are united, and we are optimistic we will have effective COVID-19 treatments and a vaccine in the near future.
Yes, KU Cancer Center’s proactive safety measures for both patients and staff have been a tremendous success. We have provided a safe environment for our patients and continue to demonstrate to our patients the extra steps we have taken including physical distancing and cleaning protocols, temperature and symptom screening, limiting access and people in certain high-risk areas, as well as staff and patient COVID testing.
Our multidisciplinary care setting has helped us greatly during this time. Rather than a patient having to go to several offices with different rules, precautions, etc., our approach to care as well as our interdisciplinary communications helps us provide consistent, stable care. Experiencing cancer is stressful enough, we want to make it as easy as possible for our patients.
There are several leadership and taskforce committees looking at education, prevention, research, communication and cancer center resources. We have numerous options for both patients and staff to be tested for COVID-19 for their safety and our cancer center community. During the last two weeks of March, while the above measures were implemented, we had a mild decrease of patients in clinic and treatment but since then we have been fully operational.
The COVID-19 infection rate among staff providing oncology patient care is ~1%.
We know we must remain nimble in the ever-changing situation. Our multidisciplinary approach to care, with our solid research infrastructure, allows us to look at challenges from all angles and move forward quickly with solutions.
Local, state and federal guidelines could impact us, however KU Cancer Center is prepared and we do not anticipate decreased patient volumes. We continue to communicate to our patients that KU Cancer Center is doing everything possible to keep them safe and that cancer care should continue during the pandemic.
We all want to be with friends and family for the holidays, however we need to protect each other, our community and our patients. Transmission of the disease is relatively easy to prevent: mask up, practice physical distancing and wash your hands. Look for alternative ways to be with friends and family such as virtual dinners and activities.
Consider stopping by to see family, but stay 6+ feet apart for a limited time to show your love during this special time. The safer we can be now to limit the spread of COVID-19, the sooner we can resume normal activities. We may have to make sacrifices this holiday season, but this will make future get-togethers all the more meaningful and special.
Director, Cancer Center at Rush University Medical Center;
Associate professor, Department of Internal Medicine,
Division of Hematology, Oncology and Cell Therapy,
The Sheba Foundation Director,
Rush University Cancer Center;
System vice president of cancer services,
Rush System for Health
This second surge in COVID-19 cases does require us to implement changes to the delivery of cancer care, but our hope is that it will not disrupt our ability to provide all cancer care services.
In the best case scenario we will be able to continue to provide all cancer related services, leveraging the lessons learned from the first wave in the spring including the principles of social distancing, use of personal protective equipment, and COVID testing for patients and staff.
With respect to social distancing, we have implemented several strategies to decrease the total number of people in the medical center to enable social distancing in clinic waiting rooms and common areas where staff congregate. In particular, we have resumed visitor policies that limit the number of people entering the medical center and cancer clinics.
Likewise, we have resumed work-from-home approaches for all employees whose job functions can be performed remotely. All meetings including tumor boards continue to be held virtually.
Furthermore, we have continued to offer virtual visits to our patients as an alternative to in-person visits. We deployed this extensively at the beginning of the pandemic in the spring with upwards of 35% of our clinical encounters converted to virtual visits.
Throughout the summer we maintained approximately 10% of all ambulatory clinical encounters as scheduled virtual visits. Now with the fall surge, we are seeing an increasing interest in patients requesting scheduled virtual visits. Virtual visits help achieve social distancing goals by decreasing the number of patients in the medical center and enable family members to participate in appointments when we have limited visitor policies.
In the worst case scenario, we would need to modify our services due to limits in hospital bed capacity. In particular, limits to hospital bed and ventilator capacity impact elective surgery services. As an institution, however, we will continue to prioritize life saving and palliative cancer surgeries with the goal of not disrupting cancer services to the greatest extent possible.
Ambulatory clinical services could also be impacted if a high enough number of staff are out on sick leave due to active COVID infection or symptoms awaiting testing results. While we don’t anticipate that this would decrease capacity for ambulatory cancer services to the levels experienced in the spring, it could have an impact.
In the spring and summer, we learned how to continue to deliver cancer care to patients with active COVID infection and those in the immediate six weeks post-infection. We implemented PPE and COVID testing strategies that allow us to continue to deliver infusion and radiation therapy to cancer patients with recent COVID infections. We have developed these workflow processes for safe delivery of care in this setting and anticipate we will be able to continue to do so during this fall surge.
Furthermore, new COVID treatments and treatment protocols are improving clinical outcomes for patients with cancer and we are already seeing the impact with decreased length of stay in the hospital and decreased in ICU admissions and intubation.
We fully expect to be able to continue to provide cancer services throughout this second wave. We do not expect patient volumes to be as low as they were in the spring.
In accordance with the CDC guidelines, we are recommending that both patients and faculty/staff participate in in-person holiday celebrations limited to the members of their immediate household and otherwise participate in virtual holiday celebrations with those family and friends outside of their household.
Michael A. Thompson
Medical director, Early Phase Cancer Research Program,
Co-director, Oncology Precision Medicine Program,
Advocate Aurora Health
In the spring, cancer center responses were often dependent on local regulations and case rates. There were peaks at different sites over time, but now clearly there are high rates all over the U.S. We know that this has decreased clinical trial accrual from the spring through fall. Accrual was starting to improve and will predictably drop again as hospitals tighten up and more research staff work from home amongst other factors.
In response, in the spring, many patient visits shifted to telemedicine. However, cancer screenings, including colonoscopy, mammography, etc. slowed or stopped. We can expect stage migration from the decrease in cancer screenings.
In the best case we will extend things that worked—work from home for some workers, telemedicine/telehealth visits, changes in chemotherapy schedules, and triage and prioritization changes. We need the ability to tele-consent for research and reimbursement for time and intellectual effort involving clinical care and research.
Clinically, we restrict visitors, screen for symptoms (questions in person and/or app) and temperature at the door and ensure masking. Cleaning protocols and physical separation in waiting areas has changed. Ten percent or more visits are virtual using an embedded EMR app. Patient care is individualized and might include greater spacing between visits if doing well, chemo breaks, or oral instead of parenteral dosing.
We have more data. There are multiple COVID19 registries and meetings that have helped evaluate risks in various populations. I was involved in the crowdsourced formation of the COVID-19 and Cancer Consortium (CCC19, CCC19.org)
A series of publications (in The Lancet, ASCO 2020 annual meeting abstract, Cancer Discovery) have provided more information, including an ASH 2020 abstract looking specifically at the hematologic malignancy population. Additionally, the NCI COVID19 registry will evaluate patients with cancer that are COVID-19 positive with sequential laboratory testing and outcome tracking.
We should have multiple COVID-19 vaccines by spring 2021, although we don’t have data on the utility in cancer patients yet—we will still suggest vaccination. In a limited study, we do see antibody response despite Ig level in multiple myeloma. Additionally, more data may emerge showing that COVID-19 convalescent plasma may benefit patients when given early.
My gestalt is that treating patients in the time of COVID-19 is a risk/benefit analysis. Patients that don’t need to be seen should be seen virtually or spread out appointments. Patients that are newly diagnosed or progressing need treatment.
We did and will continue to optimize the patient experience to deliver care as best we can. We need assistance from government entities and the community to decrease the risk to our immunocompromised and at other at risk patients. I suspect we will not drop to the low volume we did in the spring for multiple reasons noted previously including learning how to handle clinics in this new environment.
There is a light at the end of this long and dark tunnel. Celebrate with your local (same home) family. Don’t travel or meet in groups outside of your immediate family. Vaccines will help, but may take until next winter to decrease risk substantially. Please, individualize your treatment strategy which may include telemedicine visits with your physician and oncology team.
Michael J. Zinner
Chief executive officer,
Executive medical director,
Miami Cancer Institute
We are extremely worried about the surge that is coming between Thanksgiving and January, because if it mirrors what happened in March and April, and then again in July, we will see a decrease in the numbers of patients screened—and a decrease in the numbers of patients we’ll be able to see.
The best-case scenario would be that things won’t get any worse than they are right now, but I don’t think that is realistic. The worst-case is that a COVID-19 spike hits us hard, affecting patients, staff and the community at a higher rate.
We learned to scale up on testing. We have a multi-step COVID-19 screening process with rapid patient and employee testing. Our surveillance testing is mandatory, much like how the flu vaccination is mandatory for our staff.
Our COVID Command Center has been refined and expanded. Information from our detailed screening is entered into a Miami Cancer Institute-designed database and through a sophisticated program, we have intense observations and contact tracing and we follow patients at home. In addition, Miami Cancer Institute has been involved in many of the COVID-19 clinical trials. Everything we learn from those helps us as we move forward in developing better treatments for the infection.
We never stopped providing cancer care during the pandemic, and we will continue to provide care. We do realize, however, that when we have a COVID-19-positive patient, for example, who is already undergoing radiation therapy treatment for a solid tumor, things will be different.
We bring those patients in through a different entrance, we move them to the end of the day, we take them out through a separate exit and we enhance our already extreme cleaning methods. At the height of the pandemic’s first wave, we were seeing about 60% of our medical oncology follow-ups virtually through telemedicine.
We are down to about 30% now, but, if this wave continues to increase, I expect we’ll go back up. As far as patient volume, I think we’ll stay at about 80% of our normal volume. I would like to stress, though, that anyone experiencing symptoms of any disease should not ignore symptoms and should not be afraid to seek care at a hospital because of COVID-19. Going to a hospital is safer than a trip to the grocery store or a restaurant. We are taking extreme precautions so that our environment is safe.
Patients should be very careful about gatherings this holiday—period. For the past 27 years, I would bring my entire family together in Miami or Massachusetts, all 20 or 25 of them, for a holiday event. This is the first time in 27 years we are canceling. We are doing a Zoom celebration instead. Social distance. Wear masks. Wash your hands. Do not gather in groups.
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