publication date: May. 8, 2020
COVID-19 slams into the nation’s capital region;
Here is the damage assessment at six institutions
By Matthew Bin Han Ong
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.
In the first effort of its sort, The Cancer Letter has compiled a damage assessment, gauging the severity of the COVID-19 outbreak in the District of Columbia, Maryland and Virginia, gathering information on populations that were struck hardest, and quantifying impact on academic cancer centers and large hospital systems.
In interviews with The Cancer Letter, leaders at Johns Hopkins University, Georgetown University, The George Washington University, Inova Health System, The University of Virginia, and Virginia Commonwealth University described their institutions’ strategies for managing workflows and resources as the region prepares to reopen.
Conversations with the leaders of cancer centers at these institutions appear here.
The questionnaire included the following:
Have you had to take austerity measures?
How has cancer care and clinical trials changed in your institution?
How is COVID-19 affecting underserved communities and populations in your catchment area?
Is there a need for a more robust system for managing public health crises at the federal level?
At this writing, there are over 30,000 confirmed cases and 1,500 deaths in Maryland. In D.C., there are over 5,600 cases and nearly 300 deaths. The number of cases in Virginia has exceeded 22,000, with a death toll of over 800. The epidemic curve continues to trend upward in the region.
“Looking back, the high transmissibility of SARS-CoV-2, particularly during asymptomatic phases of COVID-19 illness, the propensity of the virus to cause serious life-threatening illness, and the degree to which COVID-19 cases seeded throughout several regions of the country, were generally underestimated,” William Nelson, director of the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, said to The Cancer Letter.
Large hospital systems and matrix academic cancer centers in the DMV area have had to implement cost-saving measures to limit operating shortfalls caused by the COVID-19 pandemic:
Inova has eliminated 500 nonclinical positions, and implemented pay cuts for leadership and employees who are not serving on the front lines,
UVA has furloughed many of its staff members, and applied a 20% salary reduction to faculty, senior staff, leadership, and administrators through the summer,
Johns Hopkins has reduced leadership salary, limited hiring, eliminated merit increases and suspended employer retirement contributions for the coming year, and furloughed some employees, and
GW has not laid off employees or made pay cuts, but hiring is on hold.
“There are going to be health systems that don’t survive this,” John Deeken, president of Inova Schar Cancer Institute and medical director for the Inova Schar Head and Neck Cancer Program, said to The Cancer Letter. “There’ll be practices that don’t survive this.
“So, there’s definitely going to be a forced efficiency that we’ve already seen, and that, I assume, is only going to continue, because it’s not like payers are going to say, ‘Let’s go back to the banner days of 2019,’ or whatever the framework is.”
Basic and translational research, as well as clinical trials, have largely seen a setback, said Louis Weiner, director of the Georgetown Lombardi Comprehensive Cancer Center, director of the MedStar Georgetown Cancer Institute, and chair of the Department of Oncology at the Georgetown University School of Medicine.
“It is difficult to maintain momentum in the face of this pandemic,” Weiner said to The Cancer Letter. “We have numerous video meetings to assure we can sustain our research momentum, though actual wet bench experimentation is largely inactive at this point. After a brief contraction, we are ramping up our clinical trials efforts, even as a large proportion of our patients are being seen through the MedStar telehealth platform.”
As the federal response faltered, the DMV-area institutions moved quickly to comply with state and local guidelines.
While resources are dwindling and frontline personnel endure stress as waves of COVID-19 patients arrive at their facilities, none of these institutions have experienced a surge that exceeded their inpatient capacities—avoiding worst-case scenarios and patient overflows seen in New York City, Spain, Italy, and Wuhan (The Cancer Letter, May 1, April 9, April 3, March 20, March 11, 2020).
“We were clearly, as a society, not truly prepared for this,” Mitchell Smith, associate center director for clinical investigations and director of the Division of Hematology and Oncology at The GW Cancer Center, said to The Cancer Letter. “And we can argue, without getting into politics, about whose fault it was, but clearly, we were not prepared.
“Regionally, with individual institutions, my hope would be that we would get together public and private institutions, even the VA, and have a plan among ourselves, so that we’re not competing for the limited resources, and that we move patients and staff around as necessary—so that we have sort of a local-regional pandemic disaster plan, whether it’s for a pandemic or an acute natural disaster.”
While patient volumes and treatment visits for cancer patients aren’t necessarily down across the board for these institutions, the financial impact of the pandemic on university health systems and larger networks appears to mirror the challenges faced by community oncology practices.
Early data compiled by Flatiron Health and made available exclusively to The Cancer Letter show that weekly visits to community practices dropped by nearly 40%, while cancellations and no-shows have nearly doubled (The Cancer Letter, May 1, 2020).
Some conservative media outlets interpreted these data as a sign that the economy needs to reopen swiftly, due to unintended sequelae of public health measures designed to slow the spread—delayed treatments for cancer patients and financial hardships for health care providers.
“We know that patients may not be getting the screenings and early diagnoses that are crucial for better outcomes, and that community oncology practices are hurting financially,” Bobby Green, chief medical officer at Flatiron Health, said to The Cancer Letter. “But reopening the economy while ensuring the health and safety of the public is an incredibly difficult and complex balance to strike—people’s lives and their livelihoods depend on it.
“We must make informed decisions that are based on science and data, and listen to the public health experts who have outlined parameters for reopening the economy.”
SARS-CoV-2 has tipped the scale of benefits and risks in medicine on the side of potential harms, said Len Lichtenfeld, deputy chief medical officer of the American Cancer Society.
“There are areas of the country where there are virtually no cases of COVID-19, and it’s one thing to consider what you do in that circumstance, but something else entirely when you’re in a community that still has evidence of coronavirus infections, and particularly in communities where those infections are rising in number,” Lichtenfeld said to The Cancer Letter.
“So, finances, we can recover from. Death, we cannot. It’s a false choice and it’s a false premise to compare the two,” Lichtenfeld said. “Life and safety come first; finances come second, we can resolve those issues. We must never forget our core principles and to whom we have the greatest responsibility—and it’s not to our pocketbooks.”
More than half of ACS grantees report that their cancer research has been halted as a result of the COVID-19 pandemic, according to survey results released by the organization May 8.
“It is abundantly clear that the COVID-19 pandemic is having a major impact on cancer research,” William Phelps, ACS senior vice president of extramural research, said in a statement. “In some labs queried for our survey, all non-essential research had been halted, with research on COVID-19 being the only type of research being encouraged.
“In addition to the deceleration in progress against cancer, these laboratories and institutions will face significant additional costs associated with restarting the cancer research enterprise in the coming months.”
Upward trend in cases as DMV looks to reopen
The DMV region, which was expected to be the next major COVID-19 hotspot after New York, thus far appears to have succeeded in flattening the epidemic curve, with coordinated stay-at-home orders, which resulted in relatively high compliance.
“I think social distancing has really worked. It did what it was supposed to do, which was smooth out the curve, so we didn’t see the surge that New York had,” GW’s Smith said. “I can certainly see how that could have happened. But we haven’t seen a downtrend.
“The trade-off is that I think we’re going to be at this for a while. I don’t think it’s going to magically be, ‘Oh, because we tamped down the curve, it’ll still be over in two more weeks.’ I think we’re going to be at this level for a long period.
“It’s going to be an ongoing learning experience. This is not, ‘It’s gone away and we’re done.’”
The situation can change quickly, as businesses reopen and social activities resume.
“As was apparent in Germany and Singapore, reopening does come at the risk of increasing the number of newly infected COVID-19 patients,” Robert Winn, director of the VCU Massey Cancer Center and a professor in the Division of Pulmonary Disease and Critical Care Medicine, said to The Cancer Letter. “It appears that we have gotten past the first peak. I am however, very concerned about the fall and winter.”
The number of active COVID-19 cases at institutions in the DMV region range from as low as 20 at UVA, in Central Virginia, to over 300 across a network, as is the case at Inova in high-density Northern Virginia, as well as at Georgetown and across its affiliated MedStar health system, which has many hospitals throughout the region.
“We’ve certainly been impacted less than most centers thus far. We had more lead time than some of the major cities, especially in the Northeast,” Michael Williams, the Byrd S. Leavell Professor of Medicine and associate director of clinical affairs at the UVA Cancer Center, said to The Cancer Letter. “Depending on which models you look at, the peaks come at variable times.
“It’s expected that as Virginia starts to loosen statewide restrictions on usual activities, that we may see a bump in cases. We hope not to see a major surge at this point, unless something changes dramatically,” said Williams, who is also chief of the Division of Hematology and Oncology and physician lead of the Cancer Service Line at UVA. “We do anticipate that over the coming six to 12 months, before we have an effective vaccine, we’re going to see peaks and valleys of cases.
“As people get newly active, new populations get exposed and develop the infections that we’re going to see more of those, off and on. We’re looking ahead, right now, to understand what it’s going to look like as we get into the next influenza season and we start having overlap of patients, with flu and with COVID in the mix as well.”
The pandemic has catalyzed rapid uptake of telehealth and telemedicine across all health systems, which experts anticipate will become a mainstay of U.S. health care.
“For cancer care, tactics like telemedicine, pre-visit phone calls, drive-thru injection clinics, home care, and many other approaches have been rapidly deployed, and progressively perfected,” Hopkins’s Nelson said. “The patient response has been overwhelmingly positive.
“Three years from now, we will still be using many of these approaches to make cancer care, and cancer clinical trials participation, more accessible and convenient, decreasing the time spent in waiting rooms and increasing the time spent at home with loved ones.”
Racial disparities apparent in COVID-19 deaths
The overall patterns of disparities among COVID-19 patients in the DMV mimic those seen elsewhere throughout U.S. metropolitan areas.
“Unfortunately, in Richmond, 13 of the 14 COVID-19 deaths were African American,” VCU’s Winn said. “Of the 321 people who tested positive in Richmond, 61 of those were hospitalized, and of the 14 deaths, 13 of those were African Americans.
“The most important health care policy lesson is that we must stop studying our most vulnerable populations, and actually get up off our butts and address the issues in these communities with information and approaches that we already know work,” Winn said. “It has not been the lack of knowledge, but the lack of political and social will that continues to plague these communities.
“We already know that good housing, having a great education, and having access to excellent health care will improve the health of these communities. The real question is, will we really address these issues in a post-COVID-19 world?
“The second thing that this crisis has actually taught me is that you can be wealthy or poor, but if we don’t all take care of one another the COVID virus will continue to win. So, this is the one time where we all are in the same boat, literally.”
People of color are especially at risk for significant complications from the SARS-CoV-2 infection, Inova’s Deeken said.
“Since we don’t have widespread screening, we don’t know what the actual rate of infection is, unfortunately,” Deeken said. “But in terms of the patients seeking care, being diagnosed, needing testing, and therefore being diagnosed, there seems to be a high prevalence in those populations.”
In D.C., 80% of those who died from COVID-19 and whose deaths are listed on the D.C. Department of Health website were African American.
“Clearly, there’s a disparity in mortality, likely reflecting comorbidities and other health problems, but also socioeconomics,” GW’s Smith said. “So, yes, we do see disparities in who ends up in the ICU. That’s a big concern.”
Minority populations, the poor and the uninsured are especially vulnerable to poor outcomes, because of comorbid conditions—an existing public health crisis that requires federal attention.
“This system should finally tackle the underlying public health challenge of obesity, high blood pressure, cigarette smoking, and diabetes, especially in poor and underserved populations, as if it were a crisis,” Hopkins’s Nelson said.
Experts: Failure of federal leadership
As the White House failed to provide consistent leadership, DMV institutions looked to state and local authorities:
“At the local, regional, and at the state levels, I’ve been impressed with the quality of response,” UVA’s Williams said. “At the federal level, my opinion is that the coordination has been less organized and effective and less measured in terms of emergency management and in setting priorities.”
VCU’s Winn agreed: “There has been a complete failure of leadership from the very top. I also have to give credit to the various health systems in Virginia that decided to work together for the greater good. It was tough, and probably strange, for many of these systems to have to work together in the manner in which they did.
“I think that there should have been more clarity and thoughtfulness, and consistency from the highest office of the land, it would have helped out a lot.”
Federal officials have missed many opportunities to mitigate the crisis over the last few months, Inova’s Deeken said. “I think we’ve all seen the challenges with not having a robust public health system and rapid response from the federal level, and states being left to do many initiatives on their own,” he said.
Public health systems in the U.S. aren’t as robust as they are in many other developed countries.
“Frankly, when you look at our CDC response, compared to other countries, it fell short,” GW’s Smith said. “Our testing, even now, is not where we would like it to be. Hopefully, this is a true wake-up call and we will be ready next time. One can only hope, but it has to be at the federal level.”
The U.S. needs rapid, better-coordinated early responses to emerging pandemics, Georgetown’s Weiner said.
“These responses are needed to accelerate drug development, expand distribution networks and develop/implement testing for active and prior infections,” Weiner said. “Had we done this with COVID-19, it would have blunted the devastating impact of this virus.”
Balancing the scales
As restrictions are eased, keeping the public healthy while ensuring that businesses remain viable is a precarious balancing act—even as hospitals and practices bear the brunt of responding to a surge of COVID-19 patients and deal with the deficits that come with movement control orders and economic recession.
“Cancer centers are having difficulty, just like hospitals and medical practices—and particularly primary care medical practices—when it comes to financial issues,” ACS’s Lichtenfeld said. “They’ve been caring for patients as best they can, but certainly not at the level of activity that they have in the past.
“However, we’re getting ourselves into a false choice—by opening full-throttle, versus paying attention to the virus, versus considering the economic factors,” Lichtenfeld said. “We’re talking about human lives, and first and foremost, medical organizations and medical practitioners have an absolute, absolute ethical responsibility to preserve life and keep people safe.”
Pandemic or not, patients with cancer require high-quality care in a timely fashion, said Richard Schilsky, chief medical officer and executive vice president of the American Society of Clinical Oncology.
“While the pandemic has clearly disrupted many aspects of cancer care, our job still is to deliver the best care as safely and sensibly as possible in the face of this or any public health crisis,” Schilsky said to The Cancer Letter. “ASCO recognizes that cancer care delivery teams are doing their best to protect the safety of their patients and providers, to maintain adequate staff, and to be available to patients whenever necessary. We remain committed to doing all that we can to help our members and the entire cancer community serve their patients during this difficult time.”
Safeguarding patients with cancer from the coronavirus poses unique challenges for screening and treatment interventions, said Otis Brawley, the Bloomberg Distinguished Professor of Oncology and Epidemiology at Johns Hopkins University.
“We definitely need to have a balance,” Brawley said to The Cancer Letter. “That balance must take into account the true advantages of each of our interventions and the risk of exposure to SARS-CoV-2.
“Treatment of certain faster-growing tumors needs to continue with very limited delay. Pancreatic surgery, some lung cancer treatments, therapy for many of the faster growing leukemias and lymphomas need to continue and should not take much of a holiday for COVID. These patients do need to be extremely careful not to catch the disease.”
For patients who would normally receive adjuvant therapy—for instance, after breast, colon, and lung cancer surgery—the benefit of chemotherapy may not outweigh the increased risk of getting the virus and having a bad outcome from COVID, Brawley said.
“Unfortunately, we have to use ‘may’ as no one can fully quantify this. We can quantify half,” Brawley said. “We know how to calculate the benefit in terms of preventing tumor relapse, but not the risk of getting COVID or dying from it.
“Some of those who are concerned about the decreased amount of screening right now believe screening contributes more to the decline in mortality than the data would suggest. They also tend to think weeks, or months, matter more than screening data would suggest.
“The studies do not suggest a great difference in women in yearly programs of mammography screening vs. every two years. The most important, in breast, colon and likely lung screening, is a regular program of screening, not one screen that might be delayed by a few months. That being said, I would not want to have a prolonged greater than a four-to-six month delay in most screening.
“I worry that a substantial number of Americans do not get optimal cancer therapy in normal times. Those people are more likely to get less-than-optimal therapy now.”