In an article published by Kutikov et al in Annals of Internal Medicine, practitioners from Fox Chase Cancer Center reviewed the challenges faced in cancer care during the COVID-19 crisis and suggested measures that may help to maintain standards of care while reducing risk of transmission as well as conserving resources.
The following reproduces verbatim or summarizes key points in their statement.
Context
The American Cancer Society estimates that nearly 5,000 new cases of cancer will be diagnosed per day in the United States this year. Initial data suggest that COVID-19 infection can be particularly severe in patients with cancer. Oncology specialists and other providers involved in diagnosis, treatment, and follow-up of patients with cancer must consider how to:
- Balance delay in cancer diagnosis or treatment against the risk for potential COVID-19 exposure
- Mitigate risks for significant care disruptions associated with social distancing
- Manage appropriate allocation of limited health-care resources.
Risk of Delay in Treatment vs Harm of COVID-19 Exposure
Current or past cancer diagnosis appears to place patients infected with COVID-19 at substantially increased risk of poor outcomes, and data have suggested that the risk of poor outcomes is higher in patients who have undergone recent surgery, systemic chemotherapy, or radiation therapy. The authors provide a graphic intended to provide guidance for nonspecialists in oncology in decisions regarding immediate vs delayed treatment in common cancer scenarios.
Risk of progression with cancer care delay is categorized as low (safe to delay > 3 months), intermediate (delay of ~ 3 months acceptable), and high (ideally immediate treatment). For example, many solid tumors (such as lung and pancreatic cancer) and some hematologic cancers (such as acute leukemia) require immediate diagnosis and treatment. Other common early-stage cancers (such as breast, prostate, cervical, and nonmelanoma skin cancers) may not. Evidence currently is not sufficient to support “one-size-fits-all” decisions for every patient.
Experienced oncology providers should exercise judgment regarding which patients need to initiate or continue treatment without or with minimal delay based on their knowledge of more aggressive tumor biology vs those in whom longer delay is possible. For patients with advanced cancers, futility of treatment in the setting of COVID-19 risk must be considered and discussed.
Compromise of Social Distancing During Care
Social distancing appears to be the most promising strategy currently to limiting transmission of infection; the strategy includes the concept of “mitigation,” in which the number of severe cases of infection in the health system at a given time is minimized to reduce preventable deaths associated with resource overload.
However, patients involved in traditional oncology care significantly disrupt this strategy, resulting in a multitude of ripple effects. Clinic visits, surgical stays, infusion sessions, radiation planning and treatment appointments, hospital admissions, phlebotomy visits for laboratory tests, and radiographic imaging studies (often including presence of family members) result in a large number of personal contact points and corresponding potential for COVID-19 transmission.
Similar considerations apply to clinical trials, considered standard of care for many patients with locally advanced or advanced cancers. The National Cancer Institute and the U.S. Food and Drug Administration have issued preliminary guidance regarding such issues in clinical trials, but there remains an urgent need for clear instruction and methods to preserve the integrity of studies while enhancing patient safety during the COVID-19 crisis.
Use of nontraditional care delivery strategies and modern information technology platforms—especially for patients receiving survivorship care—presents important opportunities to minimize the negative effect of cancer care delivery on public health efforts. Many hospitals and health-care systems have instituted telehealth options for patients, and the Centers for Medicare & Medicaid Services has expanded telehealth benefits for Medicare beneficiaries during the outbreak, to allow individuals to receive health-care services without visiting a health-care facility.
Allocation of Health-Care Resources
During the current crisis, the use of ward and intensive care unit beds, ventilators, pharmaceuticals, blood products, staff, and basic medical supplies for cancer care may directly conflict with care for patients with COVID-19 infection. Most cancer care is not typically considered elective; however, with increasing resource constraints due to supply chain issues, variations in geographic needs, and reallocation of medical infrastructure to care for infected patients, difficult tradeoffs will need to be considered and instituted.
Education of providers and patients is important in this regard. With careful consideration, many standard post–acute treatment strategies that ordinarily bring patients into care centers and consume such resources—like laboratory testing, imaging, and office visits—can be postponed to reduce the burden on the health-care system.
The authors concluded: “[A]s cancer care and COVID-19 collide, patients and providers will face extremely difficult choices. The combat plan during this battle must involve patience, communication, diligence, and resolve. Risks must be balanced carefully, public health strategies implemented thoroughly, and resources utilized wisely. Furthermore, the policies and procedures developed today will serve as the basis for addressing the next outbreak or similar crisis.”
Alexander Kutikov, MD, of the Department of Surgical Oncology, Fox Chase Cancer Center, is the corresponding author for the Annals of Internal Medicine article.
Disclosure: For full disclosures of the study authors, visit annals.org.
