Due to the COVID-19 pandemic, oncologists have had to balance patients' need for treatment with their risk of contracting the disease, sometimes leading them to adjust standard treatment and/or rethink its timing. These decisions have been largely informed by guidelines, research, and shared decision-making—and their complexity led one group to develop a tool that might help.
Due to the COVID-19 pandemic, oncologists have had to balance patients' need for treatment with the risk of contracting the disease, sometimes prompting them to adjust standard treatment and/or rethink its timing. Further complicating the situation, many hospitals have limited surgeries when COVID-19 cases surge and a surgical backlog once cases decrease, requiring tough decisions about the timing of operations.
Several organizations have published recommendations to help with these decisions. But Daniel Spratt, MD, of the University of Michigan School of Medicine in Ann Arbor, notes that such guidelines are typically developed for specific cancers, making it difficult to determine which surgeries should take priority or how to use other shared hospital resources.
To aid in decision-making, Spratt and his team developed oncCOVID (see http://onccovid.med.umich.edu). The tool—linked to multiple large cancer registries and the Johns Hopkins COVID-19 dashboard—assesses more than 40 factors, including patients' type and stage of cancer, age, preexisting conditions, geographic location, and the potential length of the delay. It then estimates the risk associated with delayed versus immediate treatment. “The motive behind oncCOVID is to integrate this massive amount of data into a quantitative estimate” so that patients can receive personalized care during the pandemic, Spratt explains.
Hospitals have also developed strategies for determining how to alter treatment to minimize hospital visits without compromising care. At Dana-Farber Cancer Institute in Boston, MA, for example, Ann Partridge, MD, MPH, and her colleagues developed guidelines for breast cancer care (available at www.dana-farber.org/covidmd). “Our principles were to assure [positive] long-term clinical outcomes for patients with breast cancer, minimize the risk of infection or exposure among patients and staff, avoid immunosuppression, and preserve vital resources within the healthcare system,” Partridge explains.
In practice, when Dana-Farber postponed nonurgent surgeries due to COVID-19, Partridge used hormone therapy in patients with breast cancer awaiting surgery, a strategy often used in higher-risk situations. Partridge says they were careful about choosing which treatment regimens to adjust, relying on data from patients with advanced disease: “We didn't do anything crazy.”
Stephanie Wethington, MD, of Johns Hopkins University School of Medicine in Baltimore, MD, made similar decisions to delay surgery in her patients. For example, she prescribed hormone therapy for some patients with endometrial cancer so that they could delay a hysterectomy—an accepted, although less common, approach. She also recommended neoadjuvant chemotherapy for patients with ovarian cancer and rescheduled surgeries for precancers and early-stage, less-aggressive malignancies.
Centers have further reduced in-person visits by extending the time between surveillance exams, as well as maintenance treatments, when possible. “I do think it's forced us to ask the question, ‘What is truly necessary, and what is actually optional?’” Wethington posits. “It is a very fluid process that evolved over time and continues to evolve.”
Wethington says she—and likely every oncologist—has had patients opt out of office visits due to fear of COVID-19 transmission, even in situations meriting in-person examinations. Thus, she has emphasized shared decision-making with patients, talking through patient-, cancer-, and COVID-19–specific considerations. “For some patients it can be a very complex dynamic—there is significant variation in terms of what patients feel comfortable with,” she says.
However, an important question remains: Will these changes to care negatively affect patients? “As of yet, we don't have any good data to tell us what the impact, if any, has been—we're still at a place where there is a theoretical concern,” Wethington says.
“I think any damage done, we won't really know for a long time,” Partridge agrees. –Catherine Caruso
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