The COVID-19 pandemic caused significant disruptions to virtually all aspects of oncology care. There has been a steep drop in cancer diagnoses and screenings—a result of shelter-in-place policies instituted early on, as well as ongoing patient fears about returning to healthcare facilities for new appointments or follow-up care. Experts predict that there will soon be a surge of patients with advanced cancer, which has the potential to overwhelm a healthcare infrastructure already stretched very thin. There are also unanswered questions regarding the role of telemedicine moving forward, as well as the use of alternate sites of care. These issues were addressed by a panel of healthcare experts during the virtual National Comprehensive Cancer Network 2021 Annual Conference.
Delayed Cancer Screenings
During the pandemic, healthcare institutions postponed nonessential surgeries and there was a decrease in the volume of patients who received cancer care. Routine screenings, which have been shown to reduce mortality in several types of malignancies, including colorectal, breast, and lung cancers, were also postponed or delayed. As the United States continues to open up and return to some sense of normalcy, many cancer centers are still faced with the challenge of ensuring that patients receive the care they need.
Kim Slusser, MSN, RN, CHPN, NEA-BC, Vice President, Patient Services, Yale Cancer Center/Smilow Cancer Hospital, New Haven, CT, said that more than 4000 inpatients with COVID-19 were treated at Yale New Haven Hospital during the first surge of the pandemic. She explained that although oncology services were halted at the main hospital, Yale New Haven Health’s large state network was able to maintain the volume of patients with cancer. Oncology services are still not being offered at the main hospital, where there are currently approximately 100 inpatients with COVID-19 and 7 COVID units.
“Right now, we are challenged with access to cancer services,” Ms Slusser said.
“Our experience in Utah is completely different. Our catchment area covers 1200 miles, and there has been a steady climb in the number of cases of COVID-19, but we didn’t have as many hospitalizations [as in the Northeast],” said Thomas K. Varghese, Jr, MD, MS, Chief Value Officer, Huntsman Cancer Institute, University of Utah, Salt Lake City.
Currently, the Huntsman Cancer Institute is down to between 10 and 20 patients with COVID-19. “We don’t seem to get below that,” Dr Varghese noted.
“Cancer screenings are down 60% to 80% at Moffitt Cancer Center,” noted Timothy E. Kubal, MD, MBA, Medical Director, Process Excellence, Moffit Cancer Center, Tampa, FL, who moderated the panel discussion.
The panelists agreed that although cancer screening rates are starting to rebound, they are not where they should be.
“We are nowhere near where we want to be,” Ms Slusser said. “The issue is backlog. We are trying to extend hours, but this is challenging for staffing across the board.”
“Screening remains challenging, because we still need to keep distance between patients and healthcare workers, and we are trying to recover from the backlog. We need to keep pedaling hard. It will take time, but some screenings are ‘coupling,’ so patients only have to come in for 1 visit instead of 2,” said James E. Bachman, MPA, Chief Administrative Officer, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD.
Dr Varghese said that the constraints of maintaining safety have slowed down cancer care delivery. “We are all very inefficient, between physical distancing and the need for personal protective equipment.”
The panelists noted that many people still have a lot of fear, anxiety, and misperceptions regarding the safety of hospitals and clinics, which has led to deferred cancer screening. To remedy this, campaigns targeted to the public have been created to endorse the safe resumption of cancer screening and treatment.
In Utah, because of the large catchment area, the system was ramped up to provide more vans for mobile screenings to address the screening lag, Dr Varghese noted.
Members of the panel agreed that it will take some time to return to pre-COVID screening volume, and the message to the public needs to be that hospitals and screening centers are safe places.
“Tsunami” of Advanced Cancer Cases
Studies suggest that the decline in screenings will result in more cancers being detected at advanced, and often, incurable stages. More advanced cancers will require increased capacity, which translates to longer hours and more staffing. This is coming at a time when healthcare workers are already stressed and may even be traumatized, depending on their experiences during the pandemic.
Andrew J. Wagner, MD, PhD, Associate Chief Medical Officer, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, noted that staffing remains a significant challenge. “People had to take time off for quarantining. We have increased need for staffing at a time when we are short-staffed,” he said.
Telemedicine Is Likely Here to Stay
One silver lining is the fact that telemedicine is probably here to stay. Although experiences varied depending on the center, it appears that approximately one-third to two-thirds of patient encounters were performed via telemedicine during the peak of the pandemic. Currently, telemedicine (including phone calls) accounts for approximately 20% of visits for patients with cancer.
Dr Varghese and Mr Bachman said that patients prefer in-person visits. Ms Slusser noted that patients prefer “decoupling” in-person visits. In other words, they come in once for procedures and consultations that previously required 2 or more visits.
The panelists agreed that there is a learning curve for telemedicine, but that this modality is probably here to stay in some form or another. That being the case, there is a need for best practices to address variability in patient care and safety measures.
“Telehealth is terrible for new patients. It is much better for established patients and for surveillance,” Dr Varghese stated. “It’s not just the disparity from socioeconomic status, but also it’s harder for elderly people than younger ones.”
“The value of in-person visits is in the ability for the patient to see the whole team. With telemedicine appointments, you only see 1 or 2 practitioners,” Dr Wagner added. “We are figuring out how to address the whole patient in the telemedicine visit.”
Other At-Home Services
The panel members also discussed the possibility of implementing additional at-home services to enhance patient care moving forward, including the pros and cons.
“The pandemic made us think creatively about what services could be offered at home. Convenience for patients is important,” Dr Varghese said.
“We can get stuck in our routines. The pandemic showed us that we can quickly adapt within shorter periods of time. To offer other services, we need reimbursement and to ensure quality and safety outside our facility. The administrative burden is enormous, and as we move forward with this effort, we will need more staffing,” Dr Wagner added.
“For example, with home infusion, we will need to be sure it is safe. We need systems set up to address adverse events. We need to deliver care efficiently and safely. It is hard to replicate the team approach in a home environment,” Mr Bachman noted.
“We will be pushed to offer services at home, but administering hazardous drugs is complicated. We need more nurses, pharmacists, and more time to develop an infrastructure while maintaining safety,” Dr Wagner added.
“There will be consequences. This cannot happen overnight,” Dr Varghese said.
Addressing Mental Health
Finally, the panel discussed the psychologic distress among healthcare workers and the importance of implementing policies and programs to support them.
“With the expected tsunami of late-stage patients, we need to think about the stress and fatigue among our healthcare workers. I’m very concerned, because we don’t have the luxury of stopping the train and letting everyone regroup. There are new graduates now who haven’t delivered care with visitors present. We have to offer resources, such as buddy programs,” Ms Slusser said.
“Everyone’s lives have been affected by the pandemic. We will need strong interventions for our staff. This is not a ‘one-size-fits-all’ approach,” she noted. “I’m very concerned, but the good news is that we are talking about it and making sure that we have mental health resources for our staff.”
“We need to focus on staff as we extend hours. Each organization needs to address this. We have been working so long at a breakneck clip. We need to find a way to dial it back,” Mr Bachman said.
“We have all experienced posttraumatic stress disorder,” Dr Kubal noted.
“As we get vaccinated, we need to focus on improvements and when we can get back together. The pandemic caused injury and we need to be proactive to address this,” Dr Wagner said.
Going forward, “voice your concerns, bring ideas to the table, construct solutions, and have the courage to express yourselves,” Dr Varghese advised.