publication date: Apr. 17, 2020

Conversation with The Cancer Letter

Lichtenfeld: COVID-19 exposed weaknesses in the U.S. health care system

J. Leonard Lichtenfeld

J. Leonard Lichtenfeld, MD, MACP

Deputy chief medical officer,

American Cancer Society

 

This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is available here.

How has the COVID-19 pandemic affected oncology?

What will the long-term impact be?

“The virus will expose the weaknesses of our system at many, many levels. And research is one. And health care is another. And outcomes are going to be another still,” said J. Leonard Lichtenfeld, deputy chief medical officer of the American Cancer Society.

“If there’s anything that’s good, it’s a fact that we didn’t have the number of deaths that we anticipated. Or at least it appears that we will not have a number of deaths we anticipated. Possibly, we could have had even less. But that’s a discussion for another day.

“We’re doing better than many of us thought, but there are so many areas where we have significant problems that none of us would have wanted to face.”

The Cancer Letter asked Lichtenfeld to focus on issues including:

  • The pandemic’s impact on cancer care, including telemedicine,

  • Long-term issues of cancer screening,

  • Problems of health disparities at a time of rising unemployment,

  • Potential pent-up demand for cancer care after the pandemic subsides,

  • Economic impact on private practices and cancer hospitals, including community hospitals and NCI-designated cancer centers,

  • Long-term impact on clinical and basic research.

“I think health care will come back, and there’ll be more than enough demand for health care. The problem in health care, aside from the prioritization, may be how are people going to pay for it?,” Lichtenfeld said. “Approximately 10% of our workforce, as of today, is out of work. And it may go even higher.”

 

Lichtenfeld spoke with Paul Goldberg, editor and publisher of The Cancer Letter.

 

Paul Goldberg:

Here’s the reason I’m calling: I don’t know many other people who have more breadth of knowledge in this field, everything from community oncology all the way to funding of research.

You have a model in your head, and I hope you will let The Cancer Letter take it for a spin as we try to figure out what the impact of this crisis has been and what the new normal would look like when it’s over.

My first question is: What has the COVID-19 crisis shown us about our medical system, how it operates? What do we see in oncology as a result of this?

Leonard Lichtenfeld:

I think what we’re seeing in oncology mirrors what we’ve seen systemically, that is, we were faced with a pandemic that others had talked about, but nobody had really implemented plans for.

As we moved into the COVID pandemic worldwide, oncology teams here in the United States responded by creating programs and plans and contingencies to move forward during a very acute and unusual moment in time. I have to say that from what I have seen from a larger picture, I think they’ve responded as best they can.

I currently see teams coming together, and by that I mean organizations coming together to provide more firm guidance. And I’m hopeful that as we move through the pandemic and try to get to a point of relative normalcy, we will consider what has to be done to care for our patients under those circumstances.

 

PG:

Oncology has an infrastructure for getting quick answers to hairy medical questions. Has it been put to good use?

LL:

I think we have a good infrastructure.

I’m not sure it was ever designed to respond to something as serious and as intensive as COVID-19, something that has completely disrupted our systems. I think we have a process where we can evaluate, where we can respond, but no one was prepared for something of this magnitude.

 

PG:

The clinical trials system in oncology is like no other in any other country or in any other therapeutic area.

LL:

Our clinical trials system is outstanding when it’s done right, and we owe that system a tremendous amount of gratitude for what they have done to advance cancer care and cancer research over the course of decades. However, even the clinical trials system is being faced with issues they never anticipated.

Some trials have had to be suspended. Some trials that were supposed to start could not get started, and even those that have been ongoing have had to change their metrics to respond to COVID-19. We won’t know the full impact of COVID-19 and the coronavirus on the clinical trial outcomes for some time.

We are still in that learning phase. We’re still trying to gather information. We’re still trying to make sense of what’s going on.

 

PG:

How would you use the COVID-19 crisis as a foundation for research questions?

LL:

From my perspective, we’re going to be looking at this pandemic for months and years to come. There are a number of topics.

First and foremost, what did cancer centers do in this moment of crisis? And many of the academic centers responded by going to virtual visits, by eliminating unnecessary visits, by trying to make sure that patients who needed care got the care—period. They set up triage systems to make sure that those most in need and having the most acute problems were able to get in to see the teams. And they created outreach mechanisms.

By the same token, they decided what did not have to be done. Furthermore, they responded by altering treatment courses.

They may have taken some patients, such as women with very early, non-aggressive DCIS, and initiated alternative treatments rather than going directly to surgery. At the same time, they tried to make sure the patients with the most acute demands, such as those with acute leukemia, advancing lymphoma, those receiving CAR T were able to get care.

But at the same time, we’re going to have a substantial backlog of care that’s going to have to be addressed.

I, for one, find it interesting to see how we’re going to incorporate what we have learned. In other words, we have things we want to do for our patients: treatments, scans, whatever, but now we’re learning what we have to do for patients.

Will that alter the care we offer for months to come? Those will all be the topic of research questions, to take a look at what the acute response was and what the outcomes are.

More importantly, we’re clearly going to examine long-term outcomes. In other words, were there patients who could have been treated more effectively that didn’t receive that treatment? Did it impact their outcome? Did we see increasing mortality as a result of the inability of patients to get the treatment that they needed? Epidemiologists are going to be busy for a while.

We, at the American Cancer Society, have looked at the impact of disasters in the past. We recently published a paper—in July of last year—where we looked at the impact of hurricane disasters on outcomes in early-stage lung cancer treated with radiation therapy.

Even in that circumstance, we found that the outcomes were worse for patients in disaster areas versus those who were not in disaster areas, or areas where disasters were declared. With a hurricane, you can send patients elsewhere, the disaster is fairly time limited. With this pandemic, you don’t know how long it will last, and you have no place to send your patients, because it’s nationwide.

 

PG:

What can we see on the issue of disparities?

LL:

Disparities are coming front and center on a national level.

As has been true with so many things in the pandemic, we’re examining major questions at a very high population level. We’re talking about disparities in how they impact the pandemic and the number of deaths from COVID-19 among different populations.

However, have no doubt that the same issues facing various populations—whether they be African American, Latino, or any other minority population—have no doubt that those disparities are going to magnify the outcomes for cancer patients as well.

We as a profession have to be certain that we pay attention to that problem and that we do everything in our power to make sure the care is given appropriately and given equally.

 

PG:

So, you’re saying that first we are going to see the impact of COVID in terms of disparities, but then we are going to see it again in terms of cancer care and disparities.

LL:

Yes.

 

PG:

So, it’s really a double-whammy.

LL:

Yeah, it’s going to be a double-whammy, because, as we come out of the pandemic, and we try to get back to a “normal environment,” and it won’t be normal, and those who have the least voice are at risk of being put to the back of the line. We cannot let that happen.

 

PG:

What about impact on early detection? There’s good early detection and there is bad early detection; there’s over-treatment. Is this pandemic and interruption in care going to be making it possible to study over-treatment?

LL:

I think we’re going to be seeing over-treatment a bit of a different way. We won’t call it over-treatment and we won’t call it over-detection.

What we will do is prioritize those who are a greatest need. So, for example, you’re already hearing conversations among competent and reputable oncologists and radiologists about who needs to have a mammogram the quickest. So, we have, obviously, concerns about breast cancer and early detection.

We have some women who are obviously at higher risk—for example, women with BRCA mutations and other mutations who need to be screened more regularly. They should probably go to the front of the line.

On the other hand, we know about the conflict in mammography guidelines, with some organizations saying you have to have a mammogram every year. Other organizations say you can start at age 50, every other year.

The American Cancer Society has its own set of recommendations, and you’re starting to hear some folks say, “Well, if we delay a mammogram in a woman at average risk for 18 months, that’s really not a bad thing.” So whether that ever gets incorporated into routine practice, I don’t know.

But as part of the prioritization process, I believe we will see those in greatest need, where we know we have to get the women screened on a very regular basis, even every six months, they should be screened first, and women who are at much lower risk and those who may be older, for example, may see a greater delay in terms of getting a mammogram.

You’re also seeing researchers say, “Maybe this is a good opportunity to start bringing risk-based screening into play,” that is, those where we know or where we believe there’s evidence that we can assess risk, maybe we should start applying that information to a screening procedure to try to help prioritize those who should move to the front of the line.

 

PG:

Do you think real-world evidence is being generated in sufficient depth to answer some of these questions?

LL:

I think real-world evidence is being generated. The secret will be whether we can move the real-world evidence into genuine evidence. There are some systems in place, which will be mined for all the information they can provide, because they offer it in a reasonably standard format.

The sad reality is that many of our systems don’t provide data in a fashion that can be analyzed easily. There are a lot of researchers trying to make that happen, but that research is in progress. It hasn’t gotten to the final point where we can routinely say, “We can take information from multiple systems and bring it together.”

That’s one of the difficulties that will become more apparent. We don’t have a rapid data system in place that helps us understand what’s happening today. When you talk to epidemiologists about how we can understand the impact of coronavirus and the pandemic, they’re telling us that it will take months and years to get accurate datasets, because it takes that long for data to move through the system.

Perhaps, and as a result of this pandemic, one of the beneficial consequences that may come out of it, is that we’ll find other means of getting data together, so we can understand at an earlier moment. We may not have data that’s perfect, but we should not let the perfect be the enemy of the good. We need rapid data. We need to know what’s happening.

We need to be able to implement those plans, because this may not be the only go-around we have with coronavirus. We may see a second round, possibly even a third round, because of what I believe is going to happen as we come out of this phase of the pandemic.

 

PG:

You’re talking about SEER, but what about data from the billing systems and electronic medical records and so forth?

LL:

There’s SEER data, there’s mortality data, and we know how long it takes for the validated data to become available. We will have it, and whether it’s whatever EHR one may favor, there’s no question there’s a tremendous amount of data in there. But researchers have not yet gotten to the point where they have faith in that data.

There’s a lot of information contained in medical records that is not standardized, and not accessible. Billing data still takes time to go through any system before it can be collated and analyzed. So we don’t have a good rapid response system.

And even researchers who try to rely on Medicare billing data, or private billing data, and there are some systems that do bring that data together, still have concerns about accuracy and validity. That does hinder our ability to have a quick analysis that helps us see where the problems may be. It’s not just a matter of a pandemic.

But it also has to do with our everyday research as well.

One point I think is important: We need to remember that a lot of people are getting care through telehealth, but the telehealth regulations have been substantially altered as a result of the pandemic. CMS has stepped up to the plate, changed its rules, allowed different means of communication with patients, and much of that is not captured in any way close to the routine way we do business.

So, you can use telephones, you can use facetime, but the records may not be as accurate as they were. So, we’re, we’re in the midst of, as we say, uncharted territory.

But when it comes to understanding the research issues that we face when it comes to trying to answer the research questions that are important we will still have a number of barriers to making sure that data is in a format that’s useful for the research we would like to do.

 

PG:

I started struggling with this really the first time I heard about telemedicine being used more often and in more settings: What does this do to the concept of catchment area for cancer centers, for example?

LL:

Well, actually that’s an excellent question. That’s actually two questions.

I’m going to put something first that you didn’t ask. We assume when we talk telehealth that everybody has access to online visits, and that people are comfortable doing that. I happen to be located, as we have this conversation, in a rural community. My ability to use broadband effectively is extremely limited. That’s number one.

Number Two: There are a lot of people in various communities who are not comfortable doing telehealth. They don’t have a computer, they don’t have internet, and they’re not comfortable talking to a clinician over the telephone.

So, those already are barriers that we don’t think about.

 

PG:

We’re really talking about digital divide, which is also urban-rural. Actually, that is fascinating and truly something that needs to be studied. But first, let’s dispense with my question about the impact of telehealth on catchment areas for cancer centers.

LL:

They are dealing with an issue that has some of the centers concerned, and that is, how do you do telehealth across state lines when you’re not licensed in the other state?

And I can share that I have had conversations with colleagues where that has become a real issue. So, you have the legal departments saying you can’t do a telehealth consultation from state A to state B, because you’re not licensed in state B.

And it turns out the doctor at the cancer center happens to be a national expert in a very specific area of cancer care that’s not widely available, and he or she has to make a decision whether they’re going to do that consult, and possibly be in violation of the state licensing law.

My hope is that under these circumstances ,where cancer centers have to deal with patients around the country, if not around the world, that all of us will understand that these are very special circumstances and not make a major issue about licensure in a telehealth consultation—at least during the course of this pandemic.

We could deal with the issue in normal times at a later date. But for now, we have seriously ill patients with particular diseases who are located in other states, and we should allow the experts, particularly those from the cancer centers, to interact.

I have heard one solution, and this was in the past where the center said you can do a virtual consultation in another state if that patient has already been seen and cared for in our center. The real question comes up: What happens if someone is in another state and they’d never been seen at your center and they want a consultation?

I do think that consultations between health professionals, between clinicians and doctors and other clinicians in one state to a cancer center, are probably going to be less problematic.

But the concern becomes whether another doctor in another state who hears about a doctor from the first state calling their patient in another state may not appreciate that. Could a complaint be filed? And, of course, as we all know, the answer is, yes, anybody can file a complaint about anything.

I hope that we have enough compassion and enough understanding with regard to what’s going on today, that we don’t get caught in those legal and technical dilemmas.

 

PG:

Now, let’s go through the list of areas of oncology and talk about how they qre going to be impacted. So the list is going to include the private practices, the hospitals, the cancer centers—and research funders. Let’s start with the oncology practices.

LL:

I think the impact on oncology practices is uncertain at this time. Information I’ve had from major centers—and I admit it’s not a random sample—reveals the incredible diligence and attention that most of these centers gave to the questions and the problems very early on. We know that a number of cancer centers immediately went to virtual visits.

They immediately excluded people who didn’t have to come into the center. They screened people coming in. They did everything they could to minimize the risk and exposure of the cancer patients coming in to get treatment. I also know that they paid attention to how treatment could be altered safely as a result of this pandemic.

On the other hand, we did get phone calls from cancer patients around the country. Again, far from a scientific sample, expressing concern about what was going on in the centers they were attending, the community centers and practices that they were attending.

I have no reason not to believe that most smaller programs also did what they could do to limit patient care to only what is absolutely necessary. However, I’m also aware that some centers did not, and this was a source of concern to patients.

Part of the problem, of course, is financial, and cancer practices are no different than any other medical practices. And what you see going on in the larger scene, a larger picture of medical practices, is a lot of doctors are having a great deal of difficulty, particularly those in small private practices.

But now you’re hearing reports in the news, and not necessarily about cancer practices, but other specialties, such as dermatology where in the case of private practices where there’s a heavy private equity investment, that they’re being held open, and patients were being told to come in as though nothing was wrong. And that has me extremely concerned.

I hope it’s not widespread. But I’m seeing enough reports, and actually had a personal experience to suggest that some practices were staying open in an environment where that presented increased risk to the patients they serve.

 

PG:

Will they ever be made whole at the end of this? I mean, how do they survive—or is this going to be a massacre?

LL:

My concern is that we’re going to lose some practices. There may be physicians who are near retirement age who may just say, “I quit.” Some may determine they don’t have the wherewithal or the time to make up the loss.

My understanding is that the American Medical Association and other organizations are working to keep practices whole and make sure that they have a source of funding to tide them through. But you can’t look at the private practices around this country and not be concerned.

We are at a place now where less than half of the practices are actually owned by the physicians. Less than half the practices are in the traditional model of physician ownership.

The other concern is whether the practices that are owned by private equity are going to have enough investment available to stay open. And although I hope this is not the case, are additional pressures going to be put on those practices to engage in behaviors that would be less than desirable?

I hope that’s not the case. But experience suggests to me that that may be a concern.

 

PG:

What about hospitals?

LL:

I think hospitals are going to have difficulty also. Again, the larger institutions stepped up to the plate early by putting a number of programs in place that had and will continue to have incredible cost to the institution.

There are larger medical schools and universities and hospitals, affiliated hospitals, that canceled their routine clinics, that told a good portion of their workforce to remain at home, or set up alternative arrangements, such as virtual visits, and only having the most necessary visits continue. But that costs money. Now, maybe they have deeper pockets, but even there they have fundamental fixed expenses that have to be met, and one has to have concern.

But I looked at a number of industries that have been impacted, and although I don’t believe that restaurants and medical practices are of the same intensity of service, the reality is they’re in the same boat. That is, their source of funding has been cut considerably.

And many medical practices are very much on a cash-in/cash-out basis, so any interruption may hurt. They may be able to survive for one or two months, but whether they can last three, four, or five months—is unknown. And, particularly, can they last if a second or third wave comes along.

Talking about the hospitals: There are a lot of hospitals in rural parts of this country that are already in serious financial danger. Before the pandemic hit here in Georgia, we’ve had a number of hospitals close down. And we’re not unique.

All through the country, rural hospitals are in trouble. One can only imagine what’s going to happen if in some rural communities they get overwhelmed with COVID-19, as has already occurred at southwest Georgia.

These are not hospitals that have, for the most part, large endowments. They serve communities, where a lot of their care is Medicaid,no-pay, and Medicare, and they don’t have large private insurance bases. They don’t have large private companies in many of these small towns. I’m extremely worried that we’re going to see substantial closures once this pandemic clears.

 

PG:

What about cancer centers?

LL:

Cancer centers will hopefully survive, if we’re talking about the cancer centers that enjoy excellent reputations and are NCI-level centers. My sense is that they will get through this. Now, in that scenario, what concerns me are the research programs.

We haven’t talked about research, but research can’t be ignored as having consequences and impact from COVID-19. We’ve done a non-scientific survey, where we reached out to our grantees around the country, and we received a substantial response, about 60% of the people we reached out to responded.

Half of them cannot go into their research labs at all. Almost the other half, not all, but almost the other half, are severely restricted from going into their labs.

And on the clinical side, some of the researchers who were doing the clinical or lab research have now been re-directed to working with COVID-19 patients. So the toll on research programs is highly uncertain at this point.

And how the funders, including the American Cancer Society, are going to be able to intervene and sustain those researchers is a story that is currently being written. Our hope is that we’ll be able to fund our researchers and keep them whole.

But it’s not just American Cancer Society, it’s clinical trials, it’s, obviously, NCI funding, it’s a large segment of young researchers, postdocs, for example. All of those folks are being impacted.

Once again, our major national focus is at a very, very high level. We’re looking at the highest level of population impact, and we’re concerned about many levels below that, such as the unfortunately substantial number of people who are being unemployed.

But as we have talked about, the impacts are going to go even further. They are going to go into medical practices, they’re going to go into hospitals, and they’re clearly going to go into the research enterprise—both in the clinical and the basic sciences.

 

PG:

What about issues like the uninsured?

LL:

Well, the uninsured, along with the disparities, are issues that have faced this country for a long period of time. And now we have a pandemic that is going to expose some of the most serious and worst weaknesses of our system of care.

Those who have not had access or have been denied access, and how are they going to get care today?

Today, hospitals are saying, and I have no reason to doubt them, that people who need to be in that hospital are getting care.

The virus will expose the weaknesses of our system at many, many levels. And research is one. And health care is another. And outcomes are going to be another still.

If there’s anything that’s good, it’s a fact that we didn’t have the number of deaths that we anticipated. Or at least it appears that we will not have a number of deaths we anticipated. Possibly, we could have had even less. But that’s a discussion for another day.

We’re doing better than many of us thought, but there are so many areas where we have significant problems that none of us would have wanted to face.

 

PG:

Do you have any thoughts on how one would restart the economy?

LL:

Well, I don’t know that I’m an expert in the economy.

 

PG:

You are, in one aspect of it—health care.

LL:

I think reopening the economy is going to be a bit more difficult than some people think. Some are starting to say, “Let’s get past this, and we can put everything in place, and we’ll be fine in our business.”

I focus on health care, and I think the health care economy will restart. I think it will be overwhelmed by pent-up demand. And that pent-up demand is going to be put on top of a demand that was already being stretched in many areas.

So, going back to my comments previously about prioritization, and thinking about how to get the right people in the door the earliest is so important. I think health care will come back, and there’ll be more than enough demand for health care.

The problem in health care, aside from the prioritization, may be how are people going to pay for it? Approximately 10% of our workforce, as of today, is out of work. And it may go even higher.

And if we open up too early. If we don’t do what needs to be done as we come out of this from a medical standpoint, we will quickly be back in it. Meaning, if we don’t wait until the number of cases has diminished substantially. If we don’t practice effective contact tracing, if we don’t really understand that this is not the end of this pandemic, if we don’t take all of those things to heart, we’ll be right back in the soup.

Health care as an industry has been expanding demand to fill the available opportunities. But the question is going to be who can pay for it?

Because you have so many people who had health insurance who don’t have it now. And health care has gotten so expensive that the idea of going to get care and being able to pay for it is beyond the reach of, if not every American, certainly a vast majority of Americans.

Some couldn’t pay for it before, but now people who had jobs and now don’t have jobs, how are they going to pay for it? And I don’t think we’ve come to grips with that.

One of the suggestions was to open up the ACA, at least give people an option to purchase a plan with subsidies. But best I can tell, that is not going anywhere in the near future.

So, yes, health care will be there. But the question is, how will we be able to pay for the health care people need?

 

PG:

Since we are talking, ACS has just announced austerity measures. Are you the right person to talk to about that?

LL:

We will share our official statement. However I will say that just like many non-profits, we are facing some very serious fundraising issues and we will have to make difficult choices as we move forward.

 

PG:

Is there anything I’ve missed?

LL:

We’ve covered a lot here. I think you probably have enough for a book!

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