COVID-19 Challenges Change Oncology Practice

Suresh S. Ramalingam, MD, FASCO

The COVID-19 pandemic has prompted a shift in cancer care, with institutions turning toward the use of telemedicine in a valiant effort to prevent unnecessary exposure to the virus, according to Suresh S. Ramalingam, MD, FASCO. Despite attempts to continue to provide the best care possible, however, patients are still faced with delays in treatment.

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“We are using telemedicine to help with the care of as many patients as possible,” said Ramalingam, the deputy director of the Winship Cancer Institute of Emory University. “For patients who are on long-term follow-up, who had gotten scans and were setting up a visit to review the results, we are beginning to conduct [these appointments] through telemedicine.”

Although telemedicine has afforded some patients the opportunity to continue to the next steps in their treatment journey from the safety of their own homes, others are faced with delays in their care. For example, patients who need salvage surgery are unable to undergo the operation at this time, as many hospitals have put all elective procedures on hold, according to Ramalingam. Additionally, in patients with cancer who have been infected with COVID-19, the decision might be made to delay chemotherapy treatment, as this approach can cause myelosuppression which could then increase the risk of severe complications from the virus.

“For patients, it's going to be difficult. When patients get a call saying, ‘Your visit is delayed’ or ‘Your chemotherapy is delayed,’ we just need to reassure them that we are looking into their specific situation and making a decision that is in their best interest,” said Ramalingam. “While it may be a short-term change in the overall strategy of the care plan that has been outlined to them, hopefully we will not deviate too much from the intended path and we’ll soon resume [those efforts] once we work through this crisis.”

In an interview with OncLive, Ramalingam, who is also the Roberto C. Goizueta Distinguished Chair for Cancer Research, assistant dean for Cancer Research, professor and director of the Division of Medical Oncology in the Department of Hematology and Medical Oncology, at the Emory University School of Medicine, discussed the adjustments being made in cancer care due to the rapid spread of COVID-19 and treatments under development for the virus.

OncLive: What efforts are you making to address disruptions and access to care caused by COVID-19?

Ramalingam: These are unprecedented times. We are making efforts on every front possible, and as quickly as possible, to reduce the risk of exposure to patients, their loved ones, and our faculty and staff. To do this, we are resorting to the use of more phone calls and telehealth to communicate with our patients. We are prioritizing patients based on who needs to come in versus who can be managed through a telemedicine visit and thereby reducing our patients’ risk of exposure to the virus.

We are also thinking about how to best minimize exposure [of COVID-19] to our staff who are on the front lines of caring for these patients. For example, we are considering cohorting our staff so that some staff members work virtually for 1 week while others work face-to-face [with patients] for 1 week and [these groups can] take turns. By doing so, we hope to minimize the risk of exposure. In case we need to pull them to come into work, [we hope they will be] ready, unexposed, and able to come in and help with our patient care.

How are you using telemedicine in your practice?

We are using telemedicine to help provide care to as many patients as possible. If a patient is on targeted therapy and their scans look good, we tell them, "These are the results; you don't need to come in. We'll continue on with your therapy."

Similarly, for patients who are on certain long-term therapies like immunotherapies, we are doing the visit over the phone and then telling them, "You can just go directly to the infusion center, get infused, and then go home." Those are some of the ways in which we're using telemedicine for patients who are already on active therapies and are on surveillance.

Where is COVID-19 causing the most disruptions in cancer care?

Because the systems are going into a mode where they only want to do the bare essentials of the emergency work, patients with cancer [are seeing] many downstream effects. For instance, a patient who needs surgery to have their cancer removed, now that salvage surgery is categorized as an elective procedure and most hospitals in the United States are not moving forward with those surgeries for the time being. Similarly, if a patient needs a biopsy for diagnosis or for molecular diagnosis, those biopsies are taking longer accomplish.

We are also seeing other support services going into a mode where they are only prioritizing emergencies; as a result, our cancer care is getting delayed. This is not just happening in our system. I've spoken with colleagues across the country over the past several days, and everyone is facing the same kind of challenges. Even if we are ready to do everything that we want to do for our patients today, barriers outside of our control are delaying care. It is critical that we take a hard look at each patient situation and figure out how important [each treatment approach] is for that particular patient. Is this something that can wait for 3 to 4 weeks?

We also have to keep in mind that some of the things we want to do for our patients in terms of treatment, as some may put them at higher risk for having complications related to COVID-19 infections. For example, chemotherapy can cause myelosuppression and it's possible that may increase the risk of severe complications if these patients are infected with the virus. If it is palliative chemotherapy, then we have to seriously consider whether this is something that can wait a few weeks for a patient. If a patient is deriving a great deal of benefit [from a treatment], do we continue them on it or do we hold off for some time? These are the difficult questions we're facing and asking ourselves in our clinics these days.

Do you anticipate that COVID-19 will have a long-term impact on the treatment of patients with cancer?

We are still a little too early in the curve to determine the long-term consequences of all this. Clearly, this [pandemic] has had a big impact in the short-term on our ability to continue care for our patients. My hope is that when we come out of this, we will have made significant advances in how best to provide care through the telemedicine route and how best to prioritize the care for patients. Hopefully there will not be any long-term implications for patients, even if they are exposed to [COVID-19] without having acute illnesses that would interfere with their ability to receive the optimal care for their cancers.

Are you experiencing a shortage of supplies in your practice, such as face masks and gloves?

Currently, we have an adequate number of gloves and face masks; however, these are the regular garden variety masks—not the N95 respirator masks that are optimal in this situation. I do foresee that as the number of cases grows and the situation gets more severe before it gets better, we will all have to rely on [reusing] supplies so we can manage through this difficult situation.

What is most needed to quell the COVID-19 pandemic?

The first thing that we all can do is practice social distancing, minimizing the ability of the virus to spread from one individual to another, so "flattening the curve." As a community and as a medical profession, that's something we should be advocating for. We are encouraged by the fact that clinical trials are already evaluating therapies that might work against this virus. A vaccine trial has kicked off as we speak. Hopefully these [efforts] will result in favorable outcomes for patients and be used in a widespread manner, not just for those who are [infected with] the virus, but also to minimize the risk of contacts acquiring the infection.

What are some of the research efforts being made in the fight against the virus?

A number of treatments are being explored. There are also a lot of myths out there that people have been exposed to through social media and other sources of information. I just want to stress that the most important thing is that patients should speak with their physicians and check with them before they do anything that's out of conventional path. For instance, there were cases of chloroquine toxicity that were seen in the past few weeks because folks were taking chloroquine based on what they had read. Promising options are being studied [for COVID-19], but until they are proven to be effective; we should not be advocating for them. For patients exposed to the virus, it is best that they speak with their physician before they do anything that is directed against the virus.