COVID-19 Causes Disruptions in Access to Care for Patients With Cancer

Omid Hamid, MD

To hinder the rapid spread of COVID-19 across the globe, mandatory lockdowns have been put into place to encourage the practice of social distancing, explained Omid Hamid, MD; however, efforts to prevent close contact, and thus exposure to the virus, have also caused disruptions in access to care for patients with cancer.

On March 4, 2020, Governor Gavin Newsom ordered nearly 40 million residents in the state of California to stay home, making it the first state to impose a mandatory lockdown as a regulatory intervention to prevent new infections of COVID-19.^1,2 The order, which dictates that Californian residents are not allowed to leave home except for essential purposes, is in place “until further notice.” Other states—including New Jersey,³ Michigan, South Carolina, Massachusetts, and Indiana, among others—have also ordered residents to stay home or shelter in place.⁴

“Across the country, major academic centers are focusing their resources on caring for the infirm, and we're seeing major cancer centers slowing down or even stopping accrual onto clinical trials. Patients cannot travel to be seen [elsewhere] because we are asking [everyone] not to travel,” said Hamid. “As such, access to care is going to be diminished and that's not something that many people are talking about. Just as we are trying to keep those who don't need to be seen in the emergency rooms and the hospitals away, some patients with cancer may be turned away because their acuity may not be high enough.”

In an interview with OncLive, Hamid, director of the Melanoma Center and Phase I Immuno-Oncology Program at The Angeles Clinic and Research Institute, discussed ongoing efforts to quell the COVID-19 pandemic, the benefits of telemedicine, and promising research being done to combat the virus.

OncLive: What do we know so far about COVID-19? What are some of the efforts being made to prevent the spread of the virus?

Hamid: I’m telling my patients that [COVID-19] is a very communicable virus and to date, we don't have any appropriate therapy for it. [This virus] can be airborne, it can stay on clothes, and at this point, we feel that the risk [of infection comes] from close contact with anyone who is infected.

Everyone is aware that we don't have enough information regarding the percentage [of those infected] in the United States because we are not testing [as much as other countries are]. I would stress that our population may be different than those of other countries in that we don't have enough information about those infected. What does the mortality look like? What are the ages and the comorbidities of these patients? However, that should not stop us from doing everything possible [to prevent the spread of the virus] and that means we need to [put a] stop to any activity where [people are coming] into contact with others. California just went onto mandatory lockdown, and that's [significant]. A mandatory lockdown will guarantee that [people will not be congregating in large] crowds.

Data also indicate [that even if someone is] asymptomatic, the [risk of] transmitting the virus to the elderly or the immunocompromised is great. A lot of data about herd immunity and herd toxicity [have been trending] on Twitter; if younger children [are kept] out of school and out of groups, the elderly population [then] has a decreased incidence of infection. That's important to note.

Could you expand on the patients who are most at risk of infection? What is the impact of this virus on patients with cancer specifically?

Those who are at risk are immunocompromised. Data [suggest that] in patients who have a malignancy, mortality is 3 times greater—that's significant. Patients who have any type of compromise in their cardiac, pulmonary, and renal function, [are also at risk]. For someone like my father, who is above the age of 80, already has some chronic kidney disease, and has some heart issues, these viruses are difficult.

This virus is affecting patients with cancer in a multitude of ways. Accrual for clinical trials is slowing down or stopping altogether. Access to care is being impacted as well; that’s important to be aware of. Access to care with a local doctor may also be decreased. We have general internal medicine physicians who are not seeing patients in regular follow-ups because of the concern of exposure; they need for their patients to remain uninfected. As such, general follow-ups are difficult. I ask my patients to try and ensure that they have enough medication and that they keep in contact with us. The major push here is telemedicine; through this, we can try to triage appropriately and keep patients out of the emergency rooms, out of the clinics, and at home.

What have you been telling your patients who are concerned about the virus?

I tell my patients who are receiving therapy as well as my older patients, that, “[Prevention] is not just avoiding crowds.” Efforts need to be made to keep family away, to not travel, and to not be in groups. Practice safe distances. This is not something they haven't all heard already; it's just important to stress those things. I'm also telling my patients that if they need to come in for a visit, healthcare institutes are doing everything possible to minimize risk [of infection], whether that’s cleaning more than usual or sending staff home [to decrease] risk. Physicians are also doing telemedicine to prevent patients who don't need to come in [from doing so]; that way, those who need to be seen can be treated.

What efforts are being made to address disruptions or delays in care?

The main effort, as a whole, has been to prepare our hospitals, [first and foremost]. [We need to] protect our hospitals and clinics, which means ensuring that we have enough resources and that we don't waste those resources. Patients who can be moved out 2 weeks, 4 weeks, or more, [need to be] seen through telemedicine and then [we need to] work to [bring them] in. [We need to] continue to deal with the situation and get out of this acute phase; that's really our [goal]. In our hospital, and for us at The Angeles Clinic in Los Angeles, we're affiliated with 3 separate hospitals and each of them has fallen in line with the same recommendations.

What is your personal experience with telemedicine? Are you facing any particular challenges with this approach?

For oncologists, telemedicine has not [played] a major role [in patient care]. There are ways to give an opinion on [what] the next therapy [should be], but [it’s] really difficult [to] address toxicity [associated with treatment]. We’re moving away from traditional chemotherapies [to the use of] targeted therapies and immunotherapies, and those toxicities can be severe [and sometimes] life-threatening. Eighty percent to 90% [of the patients at my clinic] are receiving immunotherapy. It’s a huge issue when someone who is on a clinical trial, or an at-risk patient who is receiving immunotherapy, calls with shortness of breath, significant fatigue, and cough; these [symptoms] can all mimic [several ailments]. What can they be? Is it pneumonia, another virus like influenza, or COVID-19? It’s very hard to take care of that [patient] via telemedicine.

Also, we're seeing many of the pulmonary complications that come on, and come on early, look like a pneumonic picture; it could be pneumonia, it could be pneumonitis, etc. We’re going to have to really work to tease those out [and determine the root of the issue]. A lot of discussion is happening [regarding these challenges].

Much of this discussion and [opportunities for] education for physicians [can be found] on Twitter. We are best suited now to disseminate information through that platform. It's interesting that in 2016, when a candidate ran [for political office] and used Twitter, it was considered to be so out of the ordinary. Now, all physicians have a voice [on Twitter] and we share information rapidly. The COVID-19 discussion is on fire on a daily basis and [we’re seeing] updates from physicians in Italy and China. Data [are also] available, so that's where I would recommend colleagues visit to see what's happening and how [others] are treating [these patients].

Those who are immunocompromised are at the highest risk for infection with COVID-19. Do you foresee immunotherapies being used less often in light of this virus?

In the metastatic setting, [the use of these agents] probably will be very minimally impacted. In the adjuvant setting, [however], it's going to be a more difficult discussion [as these agents are a standard in melanoma]; the benefits and risks have to be weighed. Hopefully, [COVID-19] is something that, as a country, we can [overcome] in the next few months and this will be only a discussion [we’re having] at this [point in] time.

I know certain groups are putting together some recommendations on how to care [for] patients in this time and how to minimize patient contact. I just [saw some] today; Susan M. Swetter, MD, of Stanford University Medical Center and Cancer Institute, and researchers, put together recommendations for adjuvant [treatment], metastatic therapies, etc. We have the ability to speak with our colleagues who are amongst those in the frontlines. For example, I text back and forth with [colleagues in] Naples, Italy [who are] dealing with [these issues to try to glean a better] understanding [of] what's going on [over there].

I can't stress how quickly information is disseminated these days; this is evidenced by what we're learning about tocilizumab (Actemra), an interleukin-6 receptor antagonist that we use for cytokine release symptoms [associated] with CAR T-cell therapy and immunotherapy. Physicians are [now] starting to use [this agent to treat] some of the major life-threatening pulmonary complications [associated with COVID-19], and anecdotally, they are [seeing] good results. [A phase III trial exploring this agent has just been approved by the FDA].

Beyond tocilizumab, are you seeing any research efforts that you find particularly promising with regard to COVID-19?

A randomized trial [is examining] hydroxychloroquine with azithromycin in patients who are positive [with the virus]; that's an interesting effort. We're all part of the clinical trials mechanism and we all try and say that a lot of this is anecdotal; it should not [be considered] standard. We need to find the answers. [We hope to do so through the] vaccine trials, medication trials, and [antiviral] trials [that are all] happening.

What is your advice to your colleagues regarding COVID-19?

My advice would be to get educated and remain dynamically educated on what's going on, what your hospital is doing, and what kind of testing is available. Do not panic. Physicians play an important role in calming down patients. This is a very stressful time where we are lacking ways to soothe. How do we self-soothe? We self-soothe through social connections. [We like to go] to places where we can [escape] our lives [for a little bit], like movie theatres, spending time with friends, or going to football or basketball games. [Even having] the ability to turn [life] on and off while we watch the Lakers [is a way to self-soothe]. We have none of that right now.

Physicians [are going to play that role] for their patients. Physicians will get a call from their patient, discuss with them, calm them down, educate them on the right things to do and the right ways to be and [they will] ensure that patients are aware that we're available to them. Healthcare professionals are always working; they're always available; that is so important for patients to know. A patient’s [favorite] restaurant may be closed, or they may not be able to go somewhere and buy something, but doctors’ offices, for the appropriate people, are always open; we have people on call. My colleagues should be working to have a psychological discussion with their patients who call in; I believe that's the first thing needed to help us get [our patients] through this [challenging] time.

References

1. White, JB. Newsom orders all 40M Californians to stay home in nation’s strictest state lockdown. Politico.com. politi.co/2QFzyg6. Accessed March 23, 2020.
2. Executive Department State of California. Executive Order N-33-20. politi.co/2xlYwua. Accessed March 23, 2020.
3. Johnson B. Murphy orders NJ residents to stay home, closes non-essential retail businesses in state lockdown to fight coronavirus. NJ.com. bit.ly/2wAzBD8. Accessed March 23, 2020.
4. Hauck G. These states are ordering residents to stay home or shelter in place. What does that mean? USAToday.com. bit.ly/2J6Qgku. Accessed March 23, 2020.