From implementing telemedical approaches to resequencing treatments, cancer centers across the nation have nimbly adapted to face the clinical challenges posed by the novel coronavirus 2019 disease.
Abraham Chachoua, MD
From implementing telemedical approaches to resequencing treatments, cancer centers across the nation have nimbly adapted to face the clinical challenges posed by the novel coronavirus 2019 disease (COVID-19). These adjustments in standard operating procedures mitigate the risk for virus spread among clinicians and patients alike.
Although the pandemic-specific protocols upheld by respective oncology institutions vary, clinicians agree that telemedicine has quickly become an invaluable component of cancer care amid the COVID-19 pandemic.
“We’ve had the ability to use telemedicine in oncology but have not rolled it out until now, in response to COVID-19,” said Abraham Chachoua, MD, in an interview with OncLive®.“We’re anticipating that it’s going to grow and interestingly, I think that’s one of the things that will stay with us after COVID-19 is under control, because once people find out what a useful [tool] it is, I don’t think you can say we’re just not going to do it anymore.” Chachoua is the associate director of Cancer Services at New York University’s Perlmutter Cancer Center in New York, New York.
The “added innovation” that the widespread adoption of telemedical methods has brought to the field of oncology constitutes a “silver lining” of the COVID-19 crisis, added Chachoua, who also serves as section chief of Medical Oncology at Perlmutter.
Many oncology centers are relying on telemedicine to facilitate consultations and other patient interactions, such as follow-up appointments, to reduce the number of patients who visit the clinic each day, as a preventive measure to stymie disease spread.
Chachoua recounted a virtual consultation with a patient with a thyroid node. “I know what my treatment plan is going to be, and it will eventually include a biopsy. This person doesn’t necessarily have to come in to see me for me to say that to her,” Chachoua said.
He added that collecting information on the patient’s demographic and family history of cancer and subsequently performing and reviewing scans are preliminary steps that he can take before he brings this patient in to the clinic for a biopsy. “Instead of doing something in 2 visits, you can do it in 1,” Chalchoua explained.
Telemedicine has also supplemented the oncology workflow at the Moffitt Cancer Center & Research Institute in Tampa, Florida, according to John A. Kolosky, CPA, MBA, chief operating officer and president of Moffitt Hospital. He said that the institution is presently using video as a medium to orchestrate what, under other circumstances, would have been in-person visits for patients and care providers. Although Moffitt Cancer Center had marginally incorporated telemedicine into their care algorithm prior to the COVID-19 pandemic, Kolosky said that the national health crisis “definitely accelerated the utilization of telemedicine” at the site.
“Patients are willing not to travel and are much more interested in getting their service via telemedicine if they can,” Kolosky said. In the time since Moffitt’s initial integration of telemedicine into its standard
operating pathway, the cancer center has tasked its telemedicine staff with training and educating clinicians on the technology, to simplify the transition from an in-person to digital format.
Importantly, the widespread adoption of telemedicine in oncology at this time can be attributed not only to increased efforts to avoid unnecessary contact but also in part to a “loosening of regulations,” said Robert J. Keenan, MD, MMM, vice president of Quality and chief medical officer at Moffitt. Keenan cited the Centers for Medicare & Medicaid Services’ (CMS) temporary expansion of Medicare telehealth services, which affords beneficiaries coverage for a broader selection of virtual health offerings for the duration of the COVID-19 public health emergency.1
Under the 1135 waiver and the Coronavirus Preparedness and Response Supplemental Appropriations Act, CMS ruled that care providers could furnish office, hospital, and other visits that would generally occur in person via telemedicine beginning March 6, 2020. The new policy mandates clinicians to use an interactive audio and video telecommunications system that can support real-time communication, and allows patients to receive this virtual care from home. Prior to this adjustment, coverage for telemedicine only applied when the patient resided in a designated rural area or when they left their home to visit a clinic, hospital, or other approved medical facility to receive the telehealth service.1
CMS’ expanded coverage of telemedicine has made the modality not only more financially feasible for some patients with cancer but also more easily accessible, and commercial payers are now following suit, according to Kolosky.
“CMS is allowing telemedicine to be used in circumstances that were not previously permitted, and now we’re seeing commercial payers be more open to the opportunity to insure telemedicine, which is helpful for the patients who would no longer face out-of-pocket expenses because it’s a covered service. This makes it more palatable for a lot of patients,” Kolosky said.
Keenan added that the Office for Civil Rights (OCR) at the Department of Health and Human Services’ recent relaxation of the Health Insurance Portability and Accountability Act (HIPPA) of 1996 also contributed to oncology centers’ implementation of telemedicine. In March, the OCR announced that healthcare providers can use any “non-public facing remote communication product” currently available to connect with patients, including Apple FaceTime, Google Hangouts, Zoom, Skype, and Facebook Messenger video chat. Under normal circumstances, the HIPPA Rules do not allow clinicians to communicate with their patients using these platforms.2
Although telehealth services such as e-visits can facilitate routine patient-physician interactions, keeping patients in touch with their clinicians yet out of the clinic while minimizing the potential for further disease spread, telemedicine is not a sufficient replacement for all patient communications, said Noelle K. LoConte, MD, associate professor of medicine at the University of Washington and coleader of the Carbone Cancer Center’s gastrointestinal disease oriented working group in Madison, Wisconsin.
“I love telemedicine for patients who are doing well, when it’s just a check in,” LoConte said. “Hospice conversations and transitions in care are where I’ve found telemedicine to be really challenging. It’s hard not to have those conversations at the bedside. I miss the opportunity to hold my patient’ hands, look them in the eye, and say, ‘I’m going to be here with you through the whole thing.’”
Facilitating check-ins and other communications digitally is critical during the COVID-19 pandemic, but it also impairs clinicians’ ability to observe patients and their family members to the extent that they normally would in an in-person appointment. “You would have the opportunity to look at patients and respond to emotion, and 1 way to respond to emotion is to read the room. If people are crying, you want to make sure to leave space for them to talk about what they’re worried about. Part of my job is to help these families get those concerns out in the open, and I’m struggling to do that over the phone,” LoConte said.
Telemedicine has allowed clinicians at Carbone Cancer Center to efficiently and effectively manage outpatient affairs, but for all of its benefits, it ultimately lacks 1 key quality: “personal touch,” LoConte said.
Modifying Therapeutic Approaches
Efforts to reduce the number of patients who come through the doors of the respective cancer clinic during the COVID-19 outbreak extend beyond telehealth services to include tweaks to treatment sequencing.
Chachoua said there have been active discussions at Perlmutter Cancer Center and at other oncology institutions about whether clinicians should defer initial surgery to instead offer patients systemic therapy or radiation therapy if these interventions would be of equal benefit, with the intention of pursuing surgery at a later date. “For example, if someone has a large lung cancer [burden], maybe you could give that patient chemotherapy first rather than surgery,” Chachoua said. “That way, you can delay the surgery by about 3 months. By then, we’re hoping that the pandemic will [be under control].”
In some cases, clinicians at Perlmutter have also given preference to a less-toxic therapeutic regimen over a more toxic counterpart, in an effort to keep patients out of the hospital from complications related to adverse events from treatment. The threat from COVID-19 has also prompted the cancer center to delay elective surgeries. Although surgical postponements occur on a case-by-case basis depending on the severity of the patient’s malignancy, Chachoua noted that several types of procedures can be safely put off.
For example, patients with “very small ground glass” lung nodules that warrant observation can wait several months before clinicians remove the nodules without added risk. Similarly, patients with “very small” breast cancers or ductal carcinoma in situ can also safely delay surgery. Although the surgical deferments are “not ideal” and represent a “change in the philosophy of how we practice,” the postponements can prevent patients from potentially being exposed to COVID-19 during an inpatient procedure and are therefore necessary adjustments to the standard, disease-specific treatment timelines.
Moffitt Cancer Center has also attempted to postpone nonurgent surgeries when possible, specifically those for which “a 30-day delay or more” would not impact a patient’s outcome, Kolosky said. “The typical chemotherapy, radiation, and surgeries are ongoing, but we have deferred the [treatments] that can be deferred.”
This is also the case at the Carbone Cancer Center, LoConte said, where, beyond surgical procedures, clinicians continue to actively identify the patients who might be able to “limit their touches with the healthcare system” by delaying chemotherapy. However, “some patients need to stay on chemotherapy and cannot take a break,” LoConte said.
It is not currently clear how long of a chemotherapeutic gap care providers could viably extend: “I’m hearing all sorts of things, from 2 weeks all the way through 5 months, and it’s very hard to make medical decisions about whether or not it’s okay to wait that long,” LoConte said.
In a recent address of members’ most frequently asked questions relative to COVID-19, the American Society of Clinical Oncology (ASCO) indicated that clinicians can consider withholding chemotherapy among patients who are in deep remission and are receiving maintenance therapy.
At Perlmutter Cancer Center, providers have sought to delay chemotherapy for some patients on maintenance regimens, to avoid bringing these patients in to the clinic. “We’re not at the point of stopping treatment altogether [and] we’re not going to do that, but there’s no reason that someone who is on maintenance chemotherapy who would be stable for a year has to come in every 3 weeks,” Chachoua said. “We could delay that treatment, so we’ve tried to do that.”
Ultimately, choices to modify or halt chemotherapy “should include consideration of the indication for chemotherapy and the goals of care,” according to ASCO. Oral therapies, for instance, could be an appropriate substitution for intravenous chemotherapy for some patients, and notably would reduce the number of clinic visits required throughout the course of treatment.3
The applicability of alterations such as these to a patient’s therapeutic course is not one size fits all, Chachoua said. “It’s a patient by patient decision and we’re trying to manipulate our treatments to keep our patients as safe as possible.”