As we react in order to protect our patients, our families, and ourselves from the global spread of COVID-19, I realized this moment also may serve as an opportunity to re-evaluate current practices we may have learned during residency or because of the dynamics of practice in our current usual work environment. Nothing is “usual” now, but we can still find ways to continue to help everyone we care about with a humane, evidence-based “less is more” approach to cancer care.
An early report from China suggests that patients with cancer have a markedly elevated risk of intubation, ICU admission, or death, both for people actively receiving treatment and for cancer survivors.1 We therefore have an ethical obligation to help our patients by both remaining involved in their cancer management and protecting them from unnecessary exposure. Further, decreasing infection rates will help lessen the burden on critical care and emergency medicine staff. How can we do both?
For patients coming for follow-up visits and no active treatment, many of these visits can be spaced out at greater intervals. How often does a patient have redundant visits with the surgeon, medical oncologist, and radiation oncologist? The National Comprehensive Cancer Network guidelines clearly give a range of acceptable time intervals.2 In the absence of symptoms, the value of physical exams may be limited for many malignancies.
I am calling my patients before a planned visit. If they feel well, we reschedule with the understanding they should call with any new symptoms and we’ll see them quickly. If symptom-based surveillance may work for lung cancer, 3 it may work for many other malignancies. Dictate a quick note after a phone call, and fewer people are put at risk of infection. Telephone follow-up and virtual monitoring can be cost effective, more convenient, and highly appreciated.4,5 Anecdotally, patients have expressed gratitude for the calls and the consideration for their health. What we lose in relative value units, we gain in trust. We have a draft outline for many malignancies. With the help of Dr. Melissa Loh, it now has more hematologic malignancies included. Dr. Enrique Soto has kindly translated it into Spanish.
Fewer follow-up visits give clinicians more time to evaluate patients with new cancer diagnoses. As we make recommendations, we should carefully consider whether the cutting-edge systemic regimens may be marginally more effective at the risk of more immunosuppression.
In radiation oncology, we can minimize extended treatments, especially with strong evidence that hypofractionation works at least as well.6,7 Single fraction radiation in palliative treatment is quite effective. For fellow radiation oncologists slow to hypofractionate, if you were not certain about when to make a change in practice, now is that time. More treatments increase risk of infection for the patient, their family, and your department staff.
For patients with metastatic disease, the issue is even more important. We cannot cure, so does progression-free survival matter to add another drug, or “consolidate” oligometastatic disease with stereotactic radiation? It seems unlikely we’re helping patients a great deal to extend times at the hospital when we can’t extend life, only relapse-free survival. For palliative radiation, single-dose or short-course treatments work well in most cases.
If patients have more symptoms from the treatments than the disease, maybe reconsider whether it’s time for a chemotherapy holiday. Why compound financial toxicity and treatment toxicity by adding infectious exposure risks?
The same principles apply to any diagnostic imaging and laboratory testing—why put hospital staff and patients at risk with more contact for testing that doesn’t change management?
There may be times in this COVID-19 pandemic that force us to compromise on optimal cancer care. But with this public health crisis comes an opportunity to improve what we do for our patients and ourselves. Love and health can flourish in difficult times, if we actively cultivate and practice it.
- Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21:335-7.
- National Comprehensive Cancer Network. Available at: https://www.nccn.org. Accessed March 8, 2020.
- Denis F, Basch E, Septans AL, et al. Two-year survival comparing web-based symptom monitoring vs routine surveillance following treatment for lung cancer. JAMA. 2019;321:306-7.
- Casey RG, Powell L, Braithwaite M, et al. Nurse-led phone call follow-up clinics are effective for patients with prostate cancer. J Patient Exp. 2017;4:114-120.
- Boyajian R, Simeoli A, Orio III PF, et al. Virtual PSA monitoring program pilot: the integration of technology in post treatment prostate cancer patient care to optimize workflow and increase access to care. Int J Radiat Oncol Biol Phys. 2018;101(3,Suppl):e101-e102.
- Shaitelman SF, Schlembach PJ, Arzu I, et al. Acute and short-term toxic effects of conventionally fractionated vs hypofractionated whole-breast irradiation. JAMA Oncol. 2015;1:931-41.
- Royce TJ, Lee DH, Keum N, et al. Conventional versus hypofractionated radiation therapy for localized prostate cancer: a meta-analysis of randomized non-inferiority trials. Eur Urol Focus. 2019;5:577-84.
ASCO has developed and compiled resources to support oncology professionals during the COVID-19 pandemic. Resources include evidence-based answers to Frequently Asked Questions (FAQs) about clinical care of patients with cancer, a centralized collection of links to credible sources, the latest decisions about impacted ASCO meetings and programs, and oncologist-vetted information for patients. This page will be updated regularly as the COVID-19 public health situation evolves.
James Freitas Fleck, MD, PhD
Mar, 31 2020 2:18 PM
Thanks, Dr. Katz!
Following the WHO statement of the COVID 19 pandemic, I also published a review of global recommendations for cancer treatment.
Please take a look and feel free to use it to help the decision-making process of our fellows in oncology.
Matthew S. Katz, MD
Apr, 02 2020 10:45 AM
Thank you for sharing, James! There are a lot of good resources coming out to help us during the pandemic, thank you for sharing your expertise. Best, Matt