From the Front Lines: Perspectives on How the COVID-19 Pandemic Is Impacting Oncology Care
Conversations With Giuseppe Curigliano, MD, PhD; Roy S. Herbst, MD, PhD, FACP, FASCO; Gilberto de Lima Lopes, Jr, MD, MBA, FAMS, FASCO; Govind Persad, JD, PhD; and Sunita Puri, MD
The long-term effects on oncology care from the COVID-19 pandemic sweeping across the globe are still being assessed, but there is no doubt they will be deep and far-reaching and may lead to substantial changes in how research and medicine are practiced.
One alarming trend starting to emerge is the impact the coronavirus is having in the African American community, which already has the highest death rate and shortest survival of any racial/ethnic group in the United States for most cancers.1 Early reports are showing that African Americans are also disproportionately at higher risk of contracting and dying from the coronavirus than other ethnic groups. According to a report released by the Centers for Disease Control and Prevention, which examined the rate of hospitalizations for patients with COVID-19 during the month of March, 33% of those hospitalized were African American, who make up 13% of the population; 45% of hospitalizations were among Caucasians, who constitute 76% of the population; and 8% of the hospitalizations were among Hispanics, who make up 18% of the population.2 Moreover, an analysis of available data by The Washington Post found that counties that are majority African American have three times the rate of infections and almost six times the rate of deaths as white-majority counties.3
The number of cases and deaths caused by the COVID-19 pandemic continues to escalate across the world. By early May, there were more than 1 million confirmed cases of the coronavirus and 68,000 deaths in the United States, which now has the highest number of cases and deaths caused by the virus than any other country. Worldwide, over 3.5 million people have been diagnosed with the coronavirus and 248,000 have died. Photo courtesy of Getty Images.
Myriad factors are at play causing the disparity, say experts, including that African Americans are less likely to have health insurance, sick leave, and job security, making it more difficult to stay at home during the pandemic. In addition, they are more likely to have comorbidities, such as hypertension, diabetes, and heart disease, making it more difficult to fend off the coronavirus, and structural racism may make it more likely they will be denied testing and treatment.4
Nevertheless, patients of all races with cancer are facing greater health-care challenges during the pandemic, as oncologists delay surgeries and reduce treatments in some cases to lessen patients’ time in the clinic and risk of infection due to immunosuppression from their cancer or treatment. (ASCO has produced a series of FAQs on COVID-19 patient care information, including whether to delay treatment in patients infected with COVID-19 and suggests that interrupting cancer treatment in patients with the coronavirus should be strongly considered, since the continuation of treatment may lead to further immunosuppression and the risk of serious complications. Additional provider and practice information can be found at asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19 and at asco.org/asco-coronavirus-information/provider-practice-preparedness-covid-19.)
The cancer research community is also experiencing setbacks, as clinical trials are suspended to protect patients and staff from infection and to shift resources to clinical studies investigating treatments and a vaccine for COVID-19. In response to the continuing spread of the coronavirus and the escalating number of deaths—as of early May, there were more than 1 million confirmed cases of the coronavirus and 68,000 deaths in the United States, with over 3.5 million confirmed cases and 248,000 deaths worldwide, according to the Johns Hopkins University Center for Systems Science and Engineering5—both the U.S. Food and Drug Administration and the National Cancer Institute have released guidelines for companies running clinical trials, as well as for physicians caring for patients on trials and recruiting patients to studies.6,7
Allocating Scarce Critical Care Resources
As the crush of thousands of critically ill patients with COVID-19 on the U.S. health-care system deepens every day, physicians are also increasingly facing the ethical dilemma of how best to allocate scarce critical care resources, such as ventilators and intensive care unit (ICU) beds, to patients most likely to survive. With no uniform, national framework—legal or ethical—in place for physicians to turn to during this crisis, the ethical and emotional burden of deciding how to allot finite health-care resources is switching from society or government to physicians. The added responsibility could exacerbate the already high rate of physician burnout in the United States, which is over 40%—and 50% for female physicians.8
In response to how the pandemic is affecting oncology care and to ensure that medical allocation decisions do not unconditionally deny patients with cancer consideration for access to scarce resources, ASCO released a set of recommendations to encourage the development of fair and equitable policies at the health-care system level.9
In this Special Report, The ASCO Post talked with five experts in the fields of oncology, palliative care, and ethics to learn how the COVID-19 pandemic is affecting patient care and cancer research. The experts include Giuseppe Curigliano, MD, PhD, Associate Professor of Medical Oncology at the University of Milan and Clinical Director, Division of Early Drug Development for Innovative Therapy at the European Institute of Oncology in Milan; Roy S. Herbst, MD, PhD, FACP, FASCO, Ensign Professor of Medicine in Medical Oncology, Professor of Pharmacology, and Chief of Medical Oncology at Yale Cancer Center and Smilow Cancer Hospital, and Associate Cancer Center Director for Translational Research at Yale Cancer Center; Gilberto de Lima Lopes, Jr, MD, MBA, FAMS, FASCO, Associate Professor of Clinical Medicine, Medical Director for International Programs, and Co-Leader of the Lung Cancer Site Disease Group at the Sylvester Comprehensive Cancer Center at the University of Miami, Editor-in-Chief of the Journal of Global Oncology, and Co-Founder of the COVID-19 and Cancer Consortium; Govind Persad, JD, PhD, Assistant Professor at the University of Denver Sturm College of Law and Greenwall Foundation Faculty Scholar in Bioethics; and Sunita Puri, MD, Assistant Professor in Clinical Medicine and Medical Director for Palliative Care at the Keck Medical Center of USC, Los Angeles.
Giuseppe Curigliano, MD, PhD: The International View
Giuseppe Curigliano, MD, PhD
The first case of COVID-19 in Italy was discovered in mid-February in the Lombardy region. The disease quickly spread throughout all 20 regions of the country, prompting the government to put its 60 million residents under lockdown. The result is that the numbers of cases and deaths from the coronavirus in the country have begun to flatten, although, as of early May, they were still the third highest in the world, behind Spain and the United States, with over 210,000 cases and nearly 28,900 deaths.5 Although restrictions on social distancing and the shuttering of schools and businesses remain intact in certain regions of the country, the national lockdown began to ease in late April.
In an interview with The ASCO Post, Dr. Curigliano, who is Associate Professor of Medical Oncology at the University of Milan and Clinical Director, Division of Early Drug Development for Innovative Therapy at the European Institute of Oncology in Milan, explained how the pandemic is affecting care for patients with cancer, discussed the toll it is taking on Italy’s health-care system, and addressed its impact on research and international collaboration.
Determining the Most Vulnerable to COVID-19
Which individuals are most affected by the COVID-19 pandemic?
Patients who have died from the coronavirus have had a mean age of 79.5 years. The mortality rate is 30% for people with cardiac heart disease and 35% for people with diabetes, and 16% of those who have died had active cancer and were undergoing treatment. This is important information: 16% of those who have died were people with active cancer.
Are patients with cancer presenting with different symptoms of the coronavirus than individuals without cancer?
No, I don’t think so. In my opinion, the numbers of cases and deaths from this virus are much higher than the figures reported. I believe we should multiply these numbers by 10 for affected people, because many people have not been tested, many are dying at home, and their deaths are not being registered as COVID-related.
We know that many of the people who are dying are over age 75 and have multiple comorbidities. When these individuals arrive at the hospital, they are often already in acute respiratory distress, and we cannot do anything to save them. There is no therapy to treat this virus. We perform intubation to help patients breathe, and we provide supportive care, but that is all we can do.
Making Life-and-Death Decisions
There have been reports of shortages of mechanical ventilators, oxygen equipment, and personal protective equipment in many hospitals in Italy, resulting in hospitals having to make difficult choices to reserve ICU beds for coronavirus patients with a reasonable chance to survive and leaving others to die. What can you tell us about this situation, and how has it impacted physicians and nurses taking care of these patients?
The Piazza del Popolo in Rome is deserted as Italy shutdown all businesses except for pharmacies and grocery stores during the height of the COVID-10 pandemic. Photo by Getty Images.
At the start of the COVID-19 outbreak, an alert went out to increase our ICU capacity, and within 2 weeks, we doubled the number of ICU beds from 5,000 to 10,000 throughout the country. We do not have shortages of ventilators or personal protective equipment, so we do not have to ration care—we can take care of all patients. We believe the high death rate from the coronavirus is due to its devasting effect on our elderly population.
That said, since the beginning of the pandemic, almost 100 physicians and 60 nurses have died. That is a huge number of health-care professionals. And according to the official data we have, 9,500 health-care professionals have tested positive for the coronavirus. In my hospital alone, 30 of the 100 health-care professionals we tested have the virus.
Prioritizing Patient Care
Is treatment for patients with cancer being delayed to reduce their risk of exposure to the coronavirus in the clinic?
Yes, we have had to prioritize patient care. In the process, we need to incorporate information about patients and the clinicobiologic characteristics of their tumors with the value-based prioritization and clinical cogency of the interventions being proposed. It is a complex, case-by-case discussion.
The priority is to treat patients with active cancer, because delaying treatment may affect their prognosis. For example, a 45-year-old with early HER2-positive breast cancer would get priority for treatment over a patient who is 75 with estrogen receptor–positive disease, because there is a higher risk of coronavirus infection for the 75-year-old patient.
Delaying Cancer Advances
What long-term impact might the pandemic have on cancer research?
I believe this pandemic will affect many areas of research. First, many companies have stopped enrollment into clinical trials, so patients are being denied the opportunity to try experimental therapies for their cancer. Then, as a result of this shutdown of clinical trials, it will take a long time to accrue patients once studies resume, and that will delay final drug approval of new agents. In terms of a long-term effect, I also expect a delay in the access to drug innovation for our patients with cancer, and I am very sorry for this, of course.
Using Technology to Enhance Collaboration
What might be the long-term impact of the COVID-19 outbreak on international collaboration in oncology care?
I don’t think there will be much of a negative impact on international collaboration, because since the pandemic began, I have been in much closer contact than ever before with my colleagues in the United States, Germany, and the United Kingdom. Although we cannot see each other in person at major oncology meetings, we are collaborating a lot online and through social media to share our experiences with COVID-19.
I believe this pandemic is actually reinforcing our collaborations because we are all facing the exact same problems in the medical oncology community, and we are sharing those experiences. This is very important, because when you are in a war like this, science will help you to share information and personal experiences, so this will not negatively impact our field over the long term.
Since ASCO is a very important global society for cancer treatment and there are thousands of members around the world, I would like to say it is important to disseminate the message that we don’t have to leave our patients with cancer behind during this pandemic. We need to take care of them exactly like we did before this outbreak.
Also there should be a lot of pressure on public officials in the United States to help them understand that to contain and mitigate this virus, the general lockdown needs to be enforced for a long time.
Roy S. Herbst, MD, PhD, FACP, FASCO: In the Laboratory and the Clinic
Roy S. Herbst, MD, PhD, FACP, FASCO
The COVID-19 pandemic is having a profound effect on patient care, and the results may last long after the crisis is over. Clinical trials across the country investigating new therapies for cancer have been halted in the wake of the COVID-19 pandemic, to protect patients from exposure to the infection as well as to transfer resources to research into therapies and a vaccine for COVID-19, potentially delaying advances in cancer treatments. Oncologists and their patients are having to determine how best to combat the twin foes of cancer and the coronavirus, as many surgeries are delayed and treatments are scaled back.
In April, during the apex of the pandemic, The ASCO Post talked with Dr. Herbst, who is Ensign Professor of Medicine in Medical Oncology, Professor of Pharmacology, and Chief of Medical Oncology at Yale Cancer Center and Smilow Cancer Hospital, and Associate Cancer Center Director for Translational Research at Yale Cancer Center, about the long-term ramifications of the pandemic on treatment advances in cancer and patient outcomes.
With scientists around the world now focused on developing effective treatments and a vaccine for COVID-19, what is the status at your institution on research for new treatments for cancer?
We have stopped nearly all clinical and basic research, and I would say that is also true in most other cancer centers. In rare instances, we are continuing to accrue patients into trials if they have a targetable genetic mutation and there is a promising drug, but most trials have been suspended.
Yale Cancer Center is associated with a large teaching, community-based hospital—Smilow Cancer Hospital at Yale New Haven—with more than 1,500 beds, and we are worried about having enough ICU beds as this pandemic spreads. So there is worry about putting patients on a trial that may cause toxicities that require hospitalization. And many trials require patients to undergo procedures that are hard to get right now, including biopsies requiring interventional radiology and specialized eligibility testing for cardiology/pulmonary cases, which are in short supply. We have also had to take a lot of our research staff to build extra teams for the ICU, so it is difficult at this critical time to focus on research.
For patients already on clinical trial protocols at Yale, we are trying our best to keep those trials going but modifying them where we can to reduce patients’ risk of immunosuppression and the worst consequences of coronavirus infection. In one protocol, for example, treatment maintenance consisted of the immunotherapy pembrolizumab and the chemotherapy pemetrexed; in some cases, we are just giving pembrolizumab because we want to avoid cytotoxic chemotherapy in patients at risk for becoming infected with COVID-19.
As researchers race to find a vaccine for COVID-19, clinical trials for cancer and other diseases are being suspended, potentially delaying advances in cancer treatment. Photo by Getty Images.
We also want to avoid bringing patients into Smilow Cancer Hospital as much as we can, because the communal transmission of the virus is very real, and we don’t have enough screening and N95 masks and personal protection equipment to protect both the staff and patients.
Another troubling result of this pandemic is that many patients with cancer are not being diagnosed because elective procedures, including surgery, are being canceled. Hence, for now, we are concentrating on working with the patients we know have cancer and getting them the best possible treatments.
Coping With the Reality of Rationing Care
How many patients with cancer have tested positive for COVID-19?
It is difficult to know how many of our patients at Smilow Cancer Hospital have the infection. Currently, we probably have about 200 patients with the coronavirus at Yale New Haven Hospital, and I know of about 20 patients with cancer who have the infection, but I am sure that number is low because so few patients have been tested. I fear that over the next few weeks, the rates of infection will increase, and we are going to see more and more patients with cancer testing positive for the coronavirus.
How is the pandemic affecting cancer care at Smilow Cancer Hospital? Are you facing medical supply shortages?
We are doing our best to provide high-quality oncology care, but some things have been lost, including face-to-face interactions with patients. We are calling on experts to take care of patients via teleconferencing when possible, and this has worked well. In some cases, this is helping us enhance care for patients with even more frequent communications.
We are experiencing limitations in N95 and surgical masks. We still have enough ventilators for patients who need them, because we have moved our oncology inpatients to another one of our hospitals to increase our ICU capacity.
Are patients with late-stage cancer at high risk for medical care rationing if they become infected with COVID-19?
Of course, this is our major concern. I take care of patients with lung cancer, and there was a time when people said not to be too aggressive with treatment for patients with metastatic lung cancer because of the dire prognosis. Now, however, when patients are diagnosed with lung cancer that has, for example, an EGFR mutation and they can receive an EGFR inhibitor, they can do very well for a long period. For some patients, immunotherapy can result in long-term survival. We can cure patients with early disease. We have ethics guidelines in place, and we are careful to include information about prognosis in patients’ charts.
I never imagined that something like this pandemic could happen. All the staff at Yale Cancer Center, Smilow Cancer Hospital, and Yale University are pulling together, and we will get through this difficult time.
Gilberto de Lima Lopes, Jr, MD, MBA, FAMS, FASCO: Tracking COVID-19 in Patients With Cancer
Gilberto de Lima Lopes, Jr, MD, MBA, FAMS, FASCO
As the global outbreak of COVID-19 continues to spread, experts are trying to determine how many individuals infected with the coronavirus also have or have had cancer and how having cancer may contribute to contraction of the virus and a worse outcome than people without cancer. The only clue so far on how vulnerable patients with cancer are to the coronavirus comes from a study in China, which used data from 1,590 patients who were infected with COVID-19 acute respiratory disease. The study found that 18 of these patients had a history of cancer and were at higher risk of a severe event requiring admission to the intensive care unit, and resulting in invasive ventilation or death.10
Because these numbers are too small to understand the full impact of the coronavirus on patients with cancer, and to learn quickly the number of patients who are infected with the virus, in March, Dr. Lopes and his colleagues launched the COVID-19 and Cancer Consortium (CCC-19). The goal of the consortium is to collect data from cancer institutions and other organizations on patients infected with the coronavirus and disseminate the information quickly, to understand the full impact of the virus on this population of patients, especially those on active cancer treatment.
As of early May, 100 cancer centers have joined the consortium, including National Cancer Institute–designated cancer centers and community practices, as well as other health-care organizations. So far, information on about 1,200 patients has been collected in the registry. The data are being collected through an online REDCap survey, which is accessible through the website https://ccc19.us.org.
(Editor’s note: In April, ASCO launched the ASCO Survey on COVID-19 in Oncology Registry to help the cancer community learn about the pattern of symptoms and severity of COVID-19 among patients with cancer, as well as the impact of the virus on the delivery of cancer care, and patient outcomes.)
The ASCO Post talked with Dr. Lopes, Associate Professor of Clinical Medicine, Medical Director for International Programs, and Co-Leader of the Lung Cancer Site Disease Group at the Sylvester Comprehensive Cancer Center at the University of Miami, Editor-in-Chief of the Journal of Global Oncology, and Co-Founder of the COVID-19 and Cancer Consortium, to learn more about the COVID-19 and Cancer Consortium, what preliminary data are showing about the full impact of the coronavirus on patients with cancer, and how to prepare for the possibility of cancer care rationing.
Why did you decide to launch the COVID-19 and Cancer Consortium?
The era of the COVID-19 pandemic has raised many new urgent clinical questions about how to care for patients with cancer, especially those infected with the coronavirus, but we don’t have any data to guide us in our decision-making. A group of us from around the country, including Jeremy L. Warner, MD, MS, FAMIA, FASCO [Associate Professor of Medicine, Hematology/Oncology at Vanderbilt University Medical Center]; Gary H. Lyman, MD, MPH, FASCO, FRCP [Senior Lead, Health Care Quality and Policy, Hutchinson Institute for Cancer Outcomes Research at the Fred Hutchinson Cancer Research Center]; Nicole M. Kuderer, MD [Advanced Cancer Research Group, Seattle], Brian Rini, MD [Chief of Clinical Trials, Vanderbilt-Ingram Cancer Center]; and Toni K. Choueiri, MD [Jerome and Nancy Kohlberg Professor, Medicine, Harvard Medical School and Attending Physician, Solid Tumor Oncology, Dana-Farber Cancer Institute], decided we had to band together to create this consortium.
Currently, 100 cancer centers and organizations in the United States are contributing data to the COVID-19 and Cancer Consortium Registry, and we just got approval to start gathering information throughout the international community as well. We will soon be adding data from Europe and Argentina and from international oncology societies and research consortia to make sure the information we gather is as broad and deep from each country as possible.
What types of information about patients infected with the coronavirus are you collecting through the REDCap survey?
All the data are clinical, including patients’ cancer type, their symptoms, whether they are receiving active treatment for cancer, type of treatment, and the course of their illness and outcome. We are not collecting any personal information that could be considered privileged or protected. We are trying to canvas as many cancer centers as possible to tease out which patients with cancer have the coronavirus and how the infection is impacting care and patient outcome.
What do you know currently about how the coronavirus affects patients with cancer?
Aside from higher rates of mortality and hospitalizations, we don’t know much. That is the whole idea behind the consortium—so that we can really understand the full impact of the pandemic on patients with cancer.
Long-Term Impact on Cancer Care
What will be the long-term impact of this pandemic on patients with cancer?
This pandemic is definitely going to have a large and long-term impact on patients with cancer, but we don’t know all of the ramifications yet. What most of us are trying to do, as you suggest, is keep patients away from the health-care system as much as possible while trying our best not to delay curative cancer treatment. We are constantly making adjustments based on patients’ individual medical needs. For example, at my institution, we are still performing surgeries for primary lung cancer. However, whenever possible, we are trying to delay surgeries for patients with breast cancer by giving them neoadjuvant treatment in the interim.
For patients who can take oral medications at home, we are making sure to get them an adequate supply of their drugs, so they can stay away from the clinic. But we have not stopped in-clinic treatments for patients who need them to survive. Unfortunately, it may come to that if the situation gets to the point where all of the hospital beds are filled with patients with COVID-19. But right now, we are still providing potentially curative treatment or treatments that may have a high impact on a patient’s outcome in the clinic.
Preparing for Worse-Case Scenarios
Are you rationing care at your institution due to limited life-saving medical equipment?
Medical centers worldwide took inventory of resources and supplies. Photo by Getty Images.
Right now, we still have adequate medical capacity and have not yet had to make any difficult decisions. But we do envision that the day may come, and we are preparing for it by getting our ethics guidelines in place, so we understand the implications of everything we may need to do.
Of course, it is always important to remember that every medical decision we make has to be made in conjunction with our patients in a shared decision-making process and weighed against the benefits and risks of every intervention. For example, if through our research we learn that patients with metastatic cancer who have had multiple treatments are not likely to survive intubation when they get to the ICU because of COVID-19, that’s an important piece of information to share with our patients.
My worry is that at some point, the decision-making between patients and physicians may not be based solely on prognosis, but on the amount of medical resources we have available.
Govind Persad, JD, PhD: Allocating Limited Medical Resources During the Pandemic
Govind Persad, JD, PhD
According to an analysis by The Washington Post, 76 million adults in the United States live in areas where patients with the coronavirus could overwhelm the supply of ICU beds, and 125 million adults live where patients could overwhelm the supply of mechanical ventilators,11 straining the capacity of the health-care system to care for every critically ill patient and setting up ethical conundrums for health-care providers. That day is already here, argues Dr. Persad, who is Assistant Professor at the University of Denver Sturm College of Law and Greenwall Foundation Faculty Scholar in Bioethics and coauthor of “Fair Allocation of Scarce Medical Resources in the Time of Covid-19,” published in The New England Journal of Medicine.12
In this interview with The ASCO Post, Dr. Persad discusses the ethical principles that need to be utilized to ensure that every patient, regardless of age or socioeconomic background, receives equitable care during times of limited medical resources.
Determining a Fair Approach to Health-Care Rationing
Please talk about the ethical values involved in rationing health-care resources during a pandemic, especially in a country that abhors the thought of that.
We often pay lip service to the idea of abhorring health-care rationing, but I wish we paid more attention to getting into a situation that requires rationing of medical care. What we are seeing with the COVID-19 pandemic is a lot of unnecessary rationing that could have been avoided if there had been enough tests for the virus and medical equipment, including personal protective equipment, intensive care beds, and ventilators, at the first signs of the outbreak. There is also the problem of people hoarding medications being touted as a potential treatment for the coronavirus, while people with a documented need for these drugs (such as chloroquine prescribed in the treatment of lupus and rheumatoid arthritis) can’t get them.
If there are health-care shortages, and even if there are no shortages, we still need a good approach to medical care rationing. I find it frustrating and a little bit implausible when people say they abhor rationing but take such inadequate steps to prevent it.
In your paper you present six recommendations for allocating medical resources during the COVID-19 pandemic. They include maximizing benefits; prioritizing health-care workers; not allocating medical care on a first-come, first-served basis; being responsive to evidence; recognizing research participation; and applying the same principles to all patients, with or without COVID-19. What are the ethical principles that led you to these conclusions, and how would these principles ensure that patients do not experience discrimination?
The most important way to ensure that patients do not experience unfair treatment and discrimination is to have ethical guidelines that are consistently followed. The way you are likely to end up in situations in which patients are treated inconsistently or arbitrarily is if you don’t have some set of clear recommendations in place for people making crucial medical decisions.
Having fair, consistent, and transparent medical-care allocation policies in place, developing prioritization guidelines, and having triage officers and physicians navigate those guidelines ensure that the choice to set limits on access to treatment is not a discretionary decision, but rather a necessary response to the overwhelming demands of the pandemic. The question is not whether to set priorities, but how to do so ethically and consistently, rather than basing decisions on individual institutions’ approaches or a clinician’s intuition in the heat of the moment, so no individual physician is ever asked to decide unaided which patients receive life-saving care and which do not.
In terms of how we identified our recommendations of the underlying principles we cite in the context of a pandemic, we reviewed guidelines from past pandemics and also looked to the ethical guidelines used in other countries, such as Australia. Our recommendations are also consistent with our prior ethical work on triaging patient care, which is already incorporated in the guidelines used by some hospitals in the United States.
Prioritizing Limited Resources
Among the recommendations you propose is the value of maximizing benefits, which calls for prioritizing limited resources aimed at saving the most lives with consideration of individuals’ posttreatment length of life. Because COVID-19 primarily affects the elderly, would this recommendation give priority to younger, healthier people who have longer to live and contribute to society?
Not necessarily. The core principle here is to try to ascertain the group of patients whose prospect of benefit increases the most if they get the scarce intervention. Although that group may often include young, severely ill patients, the goal is not to prioritize younger patients over older patients.
I want to make sure to resist what is often a mistaken reading of the value of maximizing benefits—that we should prioritize people who are healthiest and have the highest probability of survival after their illness. What we are looking for is patients who can gain the most in probability of survival, not those with the highest probability of survival irrespective of treatment.
It is absolutely true that having to prioritize scarce health-care resources in a pandemic in which some people may go without treatment that could benefit them is tragic and horrible. But if that is the situation, it is difficult to see a compelling basis for going for a value other than trying to save the most lives. Trying to save more lives when you are in a tragic situation and may not be able to treat everybody is a compelling principle that is endorsed across different ethical guidelines.
Ensuring Scarce Resources Are Fairly Allotted
How do these principles apply to patients with cancer?
We address this concern in our sixth recommendation, which states there should be no difference in allocating scarce resources between patients with COVID-19 and those with other medical conditions, including cancer. When we think about allocating any scarce resource, including access to the ICU, we look at how much that scarce resource is necessary to saving or prolonging a patient’s life.
In the case of patients with cancer, if providing care could possibly do them a lot of good, it would be ethically troubling if they were skipped over to treat more visible patients with COVID-19. It is important not to say, because we have this COVID-19 pandemic, we have to drop care for everyone else. We have to look at how we can do the most good across patient populations.
I can understand why you might want to downgrade or delay treatment for patients with cancer if the treatment is deemed elective or can be postponed. But there may be a point at which delaying treatment may substantially worsen outcomes for those patients, and that would be unethical.
Sunita Puri, MD: Role of Palliative Care During the COVID-19 Pandemic
Sunita Puri, MD
Arguably, no other field of medicine is better equipped to cope with the physical and psychosocial effects of the COVID-19 pandemic on patients than palliative care. At the core of palliative medicine is the improvement of patients’ quality of life as they undergo treatment for cancer or other illnesses, including coronavirus infection.
To learn how the practice of palliative care medicine can provide comfort for patients and their family members, as well as reduce physician burnout, during this time of medical crisis, The ASCO Post talked with Dr. Puri, who is Assistant Professor in Clinical Medicine and Medical Director for Palliative Care at the Keck Medical Center of USC, Los Angeles, and author of That Good Night: Life and Medicine in the Eleventh Hour.
Please talk about the role of palliative care during the COVID-19 pandemic. How can palliative care providers utilize their skills to respond to this crisis and provide symptom management for patients and support to family members?
This is an especially difficult time for patients infected with the coronavirus, their family members, and my colleagues because there is so much uncertainty about how this virus acts, how it affects individual patients, and who is most likely to survive the infection. In palliative care, navigating this kind of uncertainty with compassion is a very big part of what we do, and so we have a dual role during this crisis. First, we need to make sure we are treating patients’ symptoms, particularly shortness of breath if they have COVID-19. And, second, we need to help patients, family members, and clinicians make decisions that are appropriate and in line with patients’ end-of-life wishes, but that are also appropriate in the context of this pandemic.
Some of these decisions can be quite difficult because there is concern that hospitals may run out of medical equipment, such as ventilators, and not every patient may have access to life-saving equipment. So it is especially important to have these conversations, not just once but throughout the patient’s care and hospitalization.
Establishing Care Criteria During the Pandemic
Even if a patient has an advance care directive calling for every life-saving measure, if there are medical equipment shortages, the patient may not get that care.
That is correct. And even before this pandemic, it was not always possible to honor patients’ wishes to have “everything done” if they were suffering from end-stage cancer or other irreversible problems. So, it has always been the case that there may be situations in which we are not able to follow patients’ wishes. For example, if patients are so sick, putting them through cardiopulmonary resuscitation would only cause harm and suffering. Then we would instead recommend a natural death, free of suffering.
In the context of this pandemic, I encourage patients to revisit their advance care directives and to talk with their family members and their physicians about how realistic those wishes are if they suddenly become chronically ill with the coronavirus.
At my institution, if we need to allocate scarce resources, we are not considering a patient’s age when making a medical decision, but rather what the patient’s prior medical problems are and how sick they are when they come to the hospital. For example, patients with metastatic cancer whose prognosis is poor may not benefit from ICU-level care, both in the context of COVID-19 and before the pandemic.
Utilizing this pandemic to initiate these conversations is perhaps the best use of this unfortunate crisis. Oncologists can now say to patients with advanced-stage cancer, “You are vulnerable to getting very sick if you get this virus. You are already very sick. I want you to know exactly what that means from my perspective, and I want to hear what you would want if you were to get so sick you need to go to the hospital and require life support.”
Moreover, an oncologist may need to inform a patient that based on medical knowledge and experience, if the patient reaches the point of needing a ventilator or other extraordinary measures to survive—due to COVID-19 or otherwise—it would not be recommended, because these interventions may cause more suffering than benefit. There has never been a more important time for honest, clear goals-of-care discussions.
Using Technology to Ensure Patients Do Not Die Alone
One of the most difficult aspects of this pandemic is that people with COVID-19 are dying alone, with family members having to say their goodbyes via phone or teleconferencing for fear of spreading the virus. How does this long-distance way of dying alone impact patients and their family members, as well as physicians?
The COVID-19 pandemic is forcing some dying patients and their family members to use technology to say their goodbyes. Photo by Getty Images.
The pandemic is causing me to have a lot of conversations with patients and their family members by videoconferencing, which limits my ability to connect with them as human beings—a staple in my practice.
I have suggested that families record audio or video clips of what they want to say to their loved ones, and then we can play the recordings for the patients. This is a great way to maintain a connection even when families can’t visit. We did this for a patient with COVID-19; the family appreciated having a tangible way to be in touch with their loved one, and it was very comforting for the patient.
Using Palliative Care Skills to Prevent Burnout
How can palliative care physicians, as well as other health-care professionals, keep from experiencing burnout as a result of seeing so many deaths from the coronavirus?
One advantage palliative care providers have in these circumstances is we are generally a close and particularly communicative team of professionals. We often bear witness to suffering and tragedy, and we can seek support from our team unit in dealing with what we see. I also deal with stress by talking to my friends and family, exercising regularly, and watching escapist television.
Especially in times of high anxiety and stress like we are now faced with, I encourage oncologists to reach out to palliative care physicians for help if they are experiencing burnout, as well as for support while they are caring for patients. This kind of crisis necessitates extra support for everyone involved. Oncologists should rely on us for support and know we are here to help guide them through the difficult patient care decisions they are going to have to make.
DISCLOSURE: Dr. Herbst is a consultant for AbbVie Pharmaceuticals, Armo Biosciences, AstraZeneca, Biodesix, Bristol-Myers Squibb, Eli Lilly, EMD Serrano, Genentech/Roche, Genmab, Halozyme, Heat Biologics, Infinity Pharmaceuticals, Loxo Oncology, Merck, Nektar, Neon Therapeutics, NextCure, Novartis, Pfizer, Sanofi, Seattle Genetics, Shire PLC, Spectrum Pharmaceuticals, Symphogen, Tesaro, and Tocagen; has received research support from AstraZeneca, Eli Lilly, and Merck; and is a member of the Board of Directors (nonexecutive/independent) for Junshi Biosciences. Dr. Curigliano, Dr. Lopes, Dr. Persad, and Dr. Puri reported no conflicts of interest.
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