By Varun Kumar Chowdhry, MD, and Shilpa Mukunda Chowdhry, MD
Several weeks ago, our office received a call from a terrified patient. She saw in the news that the COVID-19 infection had reached parts of the United States. She was scheduled to start adjuvant radiation therapy for a small, estrogen-sensitive, yet node-positive breast cancer. She declined adjuvant chemotherapy, making the role of radiation therapy all the more important. Due to concerns of the spreading threat, she agreed to utilize anti-estrogen therapy in order to delay radiotherapy and limit her risk of exposure.
At the time, this conversation was unusual. Our institution had been carefully following the pandemic for weeks, restricting travel to high-risk areas well before the virus made national headlines. SARS-CoV-2 seemed like a distant problem in a faraway land. We thought our canceled conference was the extent to which this disease would impact our lives. We had no idea that soon we would have to make challenging decisions on how to provide cancer care. As reports of the infection gradually began to hit closer to home, within our state, county, and then town, we began to have similar conversations with many more patients about their treatment plans. The fire that was spreading through the world had hit our doorsteps.
The past few weeks have brought many challenges to our country, with our normal lives being upended by the SARS-CoV-2 virus. With many “non-essential” activities postponed or canceled, we have been tasked with defining what “essential” means to provide cancer care. Recognizing that our population of patients is particularly vulnerable, we are approaching cancer care from a new paradigm. We care for patients with a wide spectrum of diseases, some for which treatment can be safely delayed for relatively long periods of time (especially early-stage breast cancer1 and prostate cancer2, where anti-hormonal therapies can aid in delaying radiotherapy). However, some of our patients warrant urgent and timely treatment, such as those with lung, head and neck, and anal cancer.
Generally, we are accustomed to making treatment decisions based on the best available evidence, carefully balancing clinical trial data for a specific disease in the context of an individual’s overall circumstance to come up with a treatment plan that is best for the patient. In general, we can look at a single trial or a group of trials to make a treatment decision that is applicable to the person in front of us. Now, for the first time, we must consider the implications of our treatment that lie beyond an individual patient and consider the health of the population as a whole. We must weigh the benefits of our interventions against less tangible and often nebulous questions: What is this patient’s risk of contracting SARS-CoV-2 if she must leave her home to receive treatment? If she develops COVID-19 infection, what is her risk of death? And, taking this one step further, what is the overall risk to the people around her if she does contract the infection?
With our knowledge of population health, we are forced to extrapolate epidemiologic data on the human toll of this virus from other countries into our own communities. Then, to the best of our ability, we must integrate this epidemiologic data into the clinical data that guide our decision making. As an example, for an 80-year-old woman with ductal carcinoma in situ, adjuvant therapy might not improve survival,3 while data from Italy show that risk of COVID-19 infection carries a 20% mortality in patients older than age 80.4 If our patient leaves her home to receive cancer treatment and contracts COVID-19, she could exponentially impact everyone around her, with an estimate of 2 to 3 infections per index case.5
As the toll of this disease expands, we are forced to have these difficult conversations, explaining to our most vulnerable patients that we feel that their treatment or follow-up visit should be delayed. These conversations are particularly difficult because as a disease, cancer is relatively tangible: we can see it on a scan and we can touch it, and we can see its response to our treatments. Unlike cancer, we cannot feel or touch SARS-CoV-2. And most importantly, our patients already have cancer. Accounting for population health is somewhat of an ethical challenge when caring for the individual patient. Their cancer diagnosis feels immediate and real, whereas the community risk of SARS-CoV-2 may be perceived more as a theoretical risk by our patients. While cancer is known and familiar (albeit extremely unwanted), SARS-CoV-2 was initially perceived by many in the United States as a foreign disease, a problem for faraway countries to grapple with, only recently entering our communities and threatening our patients.
Importantly, having these conversations is unsettling for us as health care providers because the entire concept of “social distancing” is against the humanity we bring to our medical practice. As a palliative physician and an oncologist, sitting with a patient and their entire family for a lengthy discussion is at the heart of what we do. We pride ourselves on being there to provide the healing touch, even a warm embrace, to our patients as they navigate the challenges of a cancer diagnosis. These are luxuries of patient care for another time, the joys of clinical practice that must be suspended. We must now manage side effects and discuss treatment options on the phone. The intricate goals-of-care discussions, with family members and multiple disciplines present in a room together, are postponed. We must continually remind ourselves that this distancing is practiced out of compassion; it is for the good of our patients and our entire society.
As COVID-19 gains a foothold in our communities, we must be humble and flexible in the face of many unknowns. We must analyze clinical trial data from a new angle, trying our best to understand where it is acceptable to delay treatment, and where it is not. The medical system is being tasked to balance care for the individual patient as well as consider the health of the entire population in a way that we never have before. We could see an increased utilization of some forms of treatment over others. For example, radiotherapy can be utilized as an alternative to surgery (such as in cases of lung cancer) as ventilators become a scarce resource. The future ramifications of COVID-19 on cancer have yet to unfold, as we learn the implications of delayed cancer screenings and treatments.
At the same time, there will be lessons learned in value-based medicine, and this experience will likely expand the scope of virtual visits and telemedicine. We have already received an immense amount of positive feedback from patients about being able to have a consultation from the comfort of their own homes, and there will be an opportunity to expand the scope of virtual visits even when we move beyond the COVID-19 pandemic. We applaud the efforts not only from our institution but from cancer centers around the country, ASCO, and ASTRO for uniting to rapidly share information and provide guidance to get us through this difficult time.
We feel that our 6-month-old son also senses the tension in the air. As a two-physician household, our phones ring into the night as we take calls from frightened patients and updates from members of our teams. He is often unable to go back to sleep on his own as we try to lie down and rest. We cannot physically distance ourselves from him—he needs our love and attention more than ever. We take this opportunity to cherish the time we can spend as a family, and try to teach him important lessons about service. As we hold him close to soothe him, we sing prayers for the well-being of the world: Samasta Loka Sukhino Bhavantu, May All the Beings, in All the Worlds, Be Happy. Our time as a family provides the fuel for us to continue to do our work, transforming our own fears into motivation to carry on as best as we can.
We wish everyone the best of health, and we pray for the well-being of all.
Dr. Varun Kumar Chowdhry is an assistant professor of oncology at Roswell Park Comprehensive Cancer Center. Follow him on Twitter @VarunChowdhryMD. Dr. Shilpa Mukunda Chowdhry is a fellow in palliative medicine in the Department of Geriatrics and Palliative Medicine at the University at Buffalo.
- Hind D, Wyld L, Reed MW. Surgery, with or without tamoxifen, vs tamoxifen alone for older women with operable breast cancer: Cochrane review. Br J Cancer. 2007;96:1025-9.
- Nabid A, Carrier N, Martin AG, et al. Duration of androgen deprivation therapy in high-risk prostate cancer: a randomized phase III trial. Eur Urol. 2018;74:432-41.
- Narod SA, Iqbal J, Giannakeas V, et al. Breast cancer mortality after a diagnosis of ductal carcinoma in situ. JAMA Oncol. 2015;1:888-96.
- Livingston E, Bucher K. Coronavirus disease 2019 (COVID-19) in Italy. JAMA. Epub 2020 Mar 17.
World Health Organization. Coronavirus disease 2019 Situation Report 46. Available at: https://apps.who.int/iris/bitstream/handle/10665/331443/nCoVsitrep06Mar2020-eng.pdf. Accessed April 8, 2020.