publication date: Jul. 31, 2020
Trials & Tribulations
Cancer care in the COVID-19 world: Adjusting to a new reality
Marcus Neubauer, MD
Chief medical officer,
The US Oncology Network
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.
Oncology practices face difficult challenges while delivering care in the middle of COVID-19, as they care for patients who are at higher risk for this potentially deadly disease. While there is still much to learn about how COVID-19 impacts various patient populations, early studies of COVID-19 patients with a history of cancer provide some insight.
In one study, researchers examined data based on 928 COVID-19 patients with active cancer, or who were in remission, and found that 13% died.1 A second study analyzed data on 800 cancer patients with COVID-19 and reported a 28% death rate.2 In contrast, the COVID-19 case fatality of patients without cancer in the U.S. is 5.9%.3
The higher death rates of cancer patients are not surprising because these individuals tend to be older with compromised immune systems. Consequently, it is imperative for all of us who provide cancer care to do everything possible to ensure a safe environment for this vulnerable population.
Implementing changes for the safety of patients and staff
Healthcare providers have had to adjust their way of doing business to accommodate the new reality created by COVID-19. Across The US Oncology Network we have seen innovation, creativity and a good deal of common sense applied to protect patients and staff. Practices have made a few of the following adjustments, adhering to CDC guidelines whenever possible:
Screening procedures: All people entering the facility have their temperatures checked and are questioned about symptoms.
Contact tracing and quarantines: For patients and staff who test positive, efforts are made to identify whom they might have exposed to the virus. Employees who are exposed and are deemed medium to high-risk are quarantined, which is extremely disruptive but necessary. In order to keep our essential health care professionals on the front lines, those exposed, but deemed low risk, are expected to stay on-site, at work.
Visitor restrictions: Gone are the days when family and friends encircle the patient to offer support during an infusion session. Today, no visitors are allowed, with an occasional exception.
Personal protection equipment
Early on, PPE was used to some extent; but now, everyone wears masks—either homemade, surgical, or N95 respirators. Patients are required to wear masks as well. Consistent with CDC guidelines, employees who do not have close contact with patients or those working behind a Plexiglass shield wear homemade face coverings because the supply of N95 and surgical masks is limited.
Providers who interact closely with patients, such as nurses and physicians, are primarily wearing N95 respirators, using a lot of hand sanitation and wiping surfaces frequently. Gowns are generally not used, unless a patient is at particularly high risk. Phlebotomists have very close contact with patients and are fully donned with N95 respirators, face shields, gowns and gloves.
Lately, we have had enough PPE, but it has taken quite some time for the supply to catch up with our needs. Before the pandemic, masks were discarded after each patient visit, but the limited supply prohibits us from doing this today. We have seen some creative strategies employed to reuse masks. Some practices are decontaminating them with UV light, while others are storing them in brown paper bags for use over several days.
Practices have implemented social distancing as much as possible by positioning chairs six feet apart from one another in the waiting room. Some practices have patients wait for their appointment in their cars, keeping them out of the waiting room. Infusion room chairs are placed as far apart as possible. Practices have gotten creative by mounting large Plexiglass shields on rollers and positioning these barriers between chairs for extra protection. Onsite schedulers and front desk receptionists are also protected by Plexiglass.
One-quarter to one-third of employees are working from home, greatly reducing the number of individuals in the clinics. Practices are scheduling patients remotely, enabling patients to leave the clinic directly after their appointment rather than walking through the facility to a scheduler’s desk.
Social distancing and PPE have proven to be better options to minimize exposure and infection than performing broad scale testing. Access to testing has simply not been available the way we had hoped. With several days needed for results and a large number of false negatives, relying on testing alone is not prudent. People with symptoms and high-risk individuals are advised to get tested.
Positives from the pandemic
While COVID-19 has been devastating to our world, it is important to look for anything positive we can learn from the experience. The following are a few things that hopefully will carry forward post-COVID:
People may continue to be more respectful of germs by covering their mouths when coughing and sneezing and by being more vigilant about hand washing and using sanitizers. Social distancing will likely exist into the future for cancer care, with practices developing new ways to keep patients and staff safe from all pathogens and viruses, not just COVID-19. Physical redesigns of facilities may be necessary to accommodate this new way of caring for patients.
Telemedicine could be a new normal if Medicare and commercial payers continue to reimburse, and The Network will continue to strongly advocate for it. Our practices are using telemedicine very effectively to engage with patients, and we believe it can continue to play a vital role in providing comprehensive care. Of course, not all visits for cancer care are conducive to telemedicine, but some are.
Post-COVID-19, more technology will likely emerge around scheduling tracking positive cases and contact tracing.
Patients and practices are meeting the challenge
Patients know they are immune-compromised and at a higher risk of getting this infection, yet most are continuing treatment. Infusion volume across The US Oncology Network is down less than 5%, and radiation volumes have not changed. Patients, for the most part, are appreciative of the extra steps practices are taking to ensure their safety. While a few may object to wearing a mask, they are the exception.
Overall, our practices are doing well. Providers are rising to the occasion, as they understand that as front-line workers, they need to be present. Some staff shortages occurred early on when a few practice employees tested positive, but infections have been limited since stringent safety measures were implemented. These protocols help protect everyone from asymptomatic individuals who may not know they have the virus.
Some employees missed work because they were concerned about their own health or were caring for a child or a sick family member. The situation really is quite complex, as employees are trying to juggle all of these new concerns, while still doing their jobs.
Frankly, I am proud of the resilience and commitment I have seen from practice staff at The US Oncology Network, as they continue to keep patient care the number one priority while often experiencing turmoil in their personal and/or professional lives.
Getting back to value-based care
While there are a lot of uncertainties to deal with during this pandemic, one thing we know for sure is that cancer care cannot wait. For some cancers, treatment delays of just a few weeks can impact outcomes. For the most part, practices have been able to continue to deliver high-quality care.
While there have been disruptions along the way and probably more to come, that will not keep us from providing the care people need. We are working around the obstacles with PPE, shields, social distancing and new policies to protect patients and staff.
Practices were in the middle of the Oncology Care Model and various value-based programs when the pandemic hit, interrupting the great progress we were making. We need to get back into the rhythm of delivering care in the value-based world while accommodating this new way of doing business.
The US Oncology Network is committed to doing everything possible during these uncertain times to provide all aspects of high-quality care while still supporting value-based initiatives. Society and the patients we serve deserve no less.