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Lessons Learned About COVID and Cancer

In March of 2020, during the first U.S. surge of the COVID-19 pandemic, MedPage Today published a story on oncology specialists from the Seattle Cancer Care Alliance (SCCA) who shared their early clinical experience in adapting patient care to the challenges posed by the pandemic. In this follow-up, we update information on the current status of cancer care delivery and additional steps taken to protect patients and providers.

Recognized as the first U.S. “epicenter” of the COVID-19 pandemic, the metropolitan Seattle area provided early leadership in developing strategies to limit the spread of the infection. The SCCA followed suit by implementing protocols to balance the need to maintain essential oncology services against the paramount issue of providing maximum safety for vulnerable patients with cancer, as well as healthcare providers. At the time, data from China indicated that patients with cancer and COVID-19 had a three to four times greater risk of mechanical ventilation, ICU admission, or death as compared with patients who had COVID-19 alone.

In an article published in the Journal of the National Comprehensive Cancer Network, SCCA clinicians and researchers addressed the challenges, decision-making processes, and tradeoffs within the context of “the reality of diminishing supplies and resources.” Writing from a forward-looking perspective, the authors delineated key issues that cancer care providers should anticipate and shared insights from their own experiences with the issues. Key points included:

  • Screening patients, visitors, and staff for respiratory symptoms at all points of entry before arrival at the outpatient clinic and diverting symptomatic individuals to a secondary screening area and evaluation for COVID-19 testing
  • Providing diverse information about infection prevention and control to patients and families and implementation of a strict stay-at-home policy for all staff members who became ill
  • Development of a multi-layer coverage system for clinics in anticipation of staffing shortages, expanded use of telemedicine, and deferral of second-opinion consultations
  • Individualizing decision making related to treatment delay
  • Anticipation of the need to reallocate hospital beds for inpatient care, the need for “creative solutions” to conserve personal protective equipment during transfer from outpatient to inpatient care, and adoption of a strict no-visitor policy
  • Preparing for the “heavy reality of rationing care”
  • A proactive approach to maintaining the physical and emotional well-being of staff and faculty

Nine months ago, seven SCCA patients had tested positive for COVID-19, not including pending and inconclusive test results. Dozens more had followed as 2020 came to a close. In an interview with MedPage Today, infectious disease specialist Catherine Liu, MD, of Fred Hutchinson Cancer Research Center and the University of Washington, reviews the SCCA experience through the first full year of the COVID-19 pandemic.

Have there been any major additions or revisions to the COVID-related procedures and protocols that were implemented early in 2020?

Liu: We have certainly made some refinements and made some updates to some of the existing protocols that we had in place, things like front-door screening of our patients and staff to try to ensure that we identify those individuals who are symptomatic early on. For example, for staff we now actually have an electronic activation process. We’ve also made some modifications to our stay-at-home/return-to-work guidance. We’ve continued to update guidance as new recommendations from the CDC and other organizations have come through. Information is sort of constantly and rapidly changing so a lot of the work over the last 6 to 7 months since that article was published has really been focused on trying to ensure that we are implementing the most up-to-date, evidence-based guidance to ensure that we keep our patients and our staff safe.

I would say probably one major change that has occurred since that article was published was that we are now doing universal masking. Basically everyone who steps foot into the cancer center, including our staff, patients, and caregivers, are required to wear a mask. This is really a key strategy among a bundle of interventions that we have in place to limit transmission. It’s hard to remember, now that we’re all so used to masking and it’s really become part of our day-to-day life, but back in the early days of the pandemic there was a lot of debate about the value of masks, who should be wearing a mask, and so forth. We’ve really learned a lot in the last couple of months, and the evidence is very compelling that this is a really key and important strategy to limiting transmission.

We’ve also increased our testing. We are doing, for example, preprocedural testing of patients. Patients who are getting admitted for chemotherapy will also get tested, and we are also doing some weekly surveillance testing for bone marrow transplant patients, as well as our patients receiving CAR T-cell therapy. These strategies are really a way for us to identify early on patients who may potentially be infected, where there might be an impact on decision making about future plans around therapies.

I guess the other thing is that we’ve really developed a lot of education. There’s constant work around education for both patients and staff, in the form of guideline documents, different letters, and messaging to patients, just to keep people up to date on the various changes that have been happening.

Does any one change stand out for having made the biggest impact on maintaining the level and quality of care?

Liu: It’s hard to say that there’s one single thing that is most helpful, because I think it’s really a combination of all of these things. It’s really being nimble and adapting and communicating changes to all the stakeholders involved, from patients to staff, as soon as those changes are made, so that everybody is on the same page and understands the rationale for the changes.

Does the clinical environment feel different today as compared with 8 or 9 months ago, when the pandemic and changes brought about by it were new?

Liu: I think so. I think we are definitely better prepared. We know what we’re facing. Back in the spring, there was a lot of unknown, and I think there was a lot of fear, a lot of uncertainty. There’s still uncertainty now. I don’t think that ever goes away completely, but I think we are better prepared. We know how we can keep our patients and staff safe, and that is critically important because I think that is often what drives fear. We know what are the essential things that can keep people safe, and we know how to implement those. We are seeing patients in our clinic right now that are close to prepandemic volumes. We have proactively reduced our transplant volumes somewhat, but not to the same degree as we did in the spring. I think we know we sort of had to move forward this time around, and so I think we are taking the lessons learned from the spring and applying them.

Going forward, what do you see as some of the challenges or unknowns that you still need to address?

Liu: I sort of see it as a challenge and an exciting opportunity that we have a vaccine … and there’s obviously a lot of excitement around this. There’s still a lot of work ahead in terms of distribution. Right now we’re focused on distributing vaccine to our healthcare workers. In the coming months we will be addressing vaccination for our patients and developing strategies to implement it. I think we also want to be talking about how to vaccinate our caregivers. As many of our patients, due to their immunocompromised systems, may not be able to mount adequate immune response, I think we’re going to want to focus on vaccinating those around the patients to provide a cocoon to protect them.

Looking back at everything that has happened over the last 8 or 9 months, would you like to have a “do-over” for anything?

Liu: When you’re dealing with a crisis like a pandemic, there is a lot of uncertainty, and the information that you have at the time changes. You have to be prepared to address those changes, especially if they are major shifts from what was known previously. I think probably what is most important is to have humility in this whole process. This is still a very new virus. I think we need to acknowledge what we do know and what we don’t know and really move forward with humility and acknowledge the limitations of what we know to those we are serving — our patients and staff. Also, to communicate the key pieces of information that we are certain about and that we can effectively implement to continue to support cancer care.

Last Updated January 22, 2021

  • Charles Bankhead is senior editor for oncology and also covers urology, dermatology, and ophthalmology. He joined MedPage Today in 2007. Follow