COVID-19 and Cancer: Practices Seek to Protect Patients, Providers From Growing Pandemic

Outpatient cancer treatment and maintenance is expanding to triage and protection of vulnerable patients as cases of COVID-19 climb across the country and states move to enact shelter-in-place orders. In doing so, they are embracing the use of telehealth while grappling with the shortage of personal protective equipment affecting the entire US healthcare system.

As of late Friday, there over 270,000 cases of COVID-19 and 227 deaths, according to Johns Hopkins University, which is tracking the number of cases globally in real time. More cases are expected to be uncovered as testing widens.

This week the Journal of the National Comprehensive Cancer Network published a special feature about what is needed to provide care to patients with cancer during the pandemic of novel coronavirus disease 2019. Based on early data from China, the report said patients with both cancer and COVID-19 had a 3.5 times higher risk of mechanical ventilation, admission to an intensive care unit, or death compared with patients without cancer.

The report was written by the specialists at the center of the pandemic in the United States—the Seattle Cancer Care Alliance, Fred Hutchinson Cancer Research Center, and the University of Washington.

The virus can spread by individuals who are asymptomatic or who may have mild symptoms that may appear as a cold, with an incubation period lasting as long as 2 weeks. Infection prevention and control is a priority; in Seattle, institutions have implemented a strict policy against coming to work when feeling ill. "A comprehensive policy for testing staff, tracking results for persons under investigation, tracing exposures, and defining return to work is essential to maintain a stable workforce," the report notes. There are also travel restrictions and telecommuting policies. And elective surgeries are being delayed.

To keep their patients out of the general public unless absolutely necessary, oncology practices are having patients not in active treatment defer their usual visits, and limiting the number of caregivers who can accompany them to treatment sessions.

Some patients with cancer are more vulnerable than others, said Jeffrey Patton, MD, acting chief executive officer and president of physician services of OneOncology, as well as chief executive office of Tennessee Oncology.

About one-third of their patients are seeing their visits postponed in order to keep them at home, such as those who are done with breast cancer treatment.

“We’re being pretty aggressive in protecting our folks,” he said in an interview with The American Journal of Managed Care (AJMC^®).

But about one-third are more vulnerable, such as those on cytotoxic chemotherapy and immunotherapy, he said. And certain types of cancers make patients more vulnerable than other types, chiefly lung malignancies and active hematologic cancers, such as non-Hodgkin lymphoma, chronic lymphocytic leukemia, acute myeloid leukemia, acute lymphoblastic leukemia, and multiple myeloma.

Besides the concern for patients, practices are scrambling for personal protective equipment (PPE). Patton said Tennesse Oncology has 2 weeks’ worth left, and that as of Friday, 7 providers are in self-quarantine.

OneOncology is a network of practices across 4 states, including in those large numbers of COVID-19 cases, such as New York, and those with some of the fewest. Providers are increasingly using telehealth to assess patients running a fever for symptoms of sepsis or low white blood cell count, to prevent unnecessary trips into the office. “The best place for them to be is at home,” said Patton. "If symptoms progress and there's shortness of breath, pneumonia, then they would have to be cared for in a hospital."

"We have done it before and now we are aggressively expanding it, now that we appropriately can get paid for it, and it’s a great way to socially isolate patients that don’t need to be either exposed to a virus or bringing virus exposure into our clinics," he said. Patton was referring to a change that CMS made earlier this week that temporarily widens the use of telehealth by agreeing to reimbursement changes during the COVID-19 national emergency.

As with the country's rapid shift to telecommuting in an effort to contain the virus' spread—Patton called it an idea that "just makes sense"—he said he hopes that the embrace of telehealth by CMS becomes permanent as well.

"If you can do it during a crisis, why can’t you do it all the time?" he asked.

Reference

Ueda M, Martins R, Hendrie PC, et al. Managing cancer care during the COVID-19 pandemic: Agility and collaboration toward a common goal [published online March 20, 2019]. J Natl Compr Canc Netw. doi: 10.6004/jnccn.2020.7560.