What Does It Take?

May 19, 2020

For years, I—like a great many other clinicians who care for patients with cancer— have wondered what it would take to change the way we deliver and pay for cancer care. While the medical science of oncology has evolved rapidly in recent years, policies and practice patterns have remained stagnant. So, what does it take to bring meaningful change to the status quo?

Apparently, it takes a pandemic.

Over the past few weeks (not months, but weeks), we’ve seen dramatic shifts in cancer patient well-being, practice patterns, clinician well-being, research, and policy, all in an attempt to cope with the COVID-19 pandemic. But what exactly are those changes, and which ones are here for the long haul?

Paying More Attention to Patients

First, special attention has been paid to how patients with cancer are impacted by COVID-19. Most of the data thus far has come from studies conducted in China and Europe. A study of 1524 patients with cancer in Wuhan, China found that 12 of those patients were infected with the SARS-CoV-2 virus. This translates to a 0.79% incidence of infection among cancer patients, versus an incidence of 0.37% in the general population. A second study that examined how cancer patients do once infected reported some concerning results: Liang and colleagues found that once infected, patients with cancer were more than 3.5 times more likely to experience invasive ventilation or death compared with the general population. And, not surprisingly, a French study found that infected cancer patients who had a worse functional status or had recently received chemotherapy were more likely to experience a worse outcome. Admittedly the data is currently limited, but it suggests that cancer patients are more likely to get infected, and when infected, more likely to do worse.

The Practice of Medicine Is Being Changed in Lasting Ways

In March, I emailed some of my colleagues—gastrointestinal oncologists like me—from all over the country and asked them how their practices were changing, and whether they were treating patients differently. The responses were almost immediate: Yes, treatment is being delayed or attenuated in some cases. Yes, clinical trials are being put on hold. Yes, risk and benefit are being carefully considered. We decided to publish our collective opinions on modifying care in patients with gastrointestinal cancer. In my personal experience, this was the fastest I had seen an idea progress from conception, to data collection, to publication.

But beyond just practice changes, clinicians have been considerably affected by the pandemic. In a survey of more than 800 physicians, most of them specialists, over one-fifth of MDs who were not treating COVID-19 patients have been furloughed or have seen a pay cut, and 14% are considering changing practices. Nearly a third of physicians who do treat patients with COVID-19 report “feeling great stress.” These are not short-term impacts: the effects of this pandemic on the physician workforce will be felt for years to come.

Changes in Cancer Research

Cancer research has not escaped the wave of disruption that the pandemic has brought in its wake. Katherine Baicker, the dean of the University of Chicago Harris School of Public Policy, said it best: “We are all COVID researchers now.” One way or another, research in coming years will either focus on COVID or will be affected by COVID. For example, the American Cancer Society released a statement in April stating, “At this point, funding of grants at any level for the next cycle cannot be guaranteed.” We will see a drop in productivity as labs shut down and slowly re-open. Site visits have been canceled and trial enrollment has been decreased. Restarting the cancer research engine will take time and considerable investment.

Coverage and Reimbursement: New Realities

To me, the rapidity with which coverage and reimbursement policies have evolved—again, a matter of weeks rather than months—has been one of the most impressive changes wrought by the pandemic. In mid-March, Blue Cross Blue Shield North Carolina announced coverage of telehealth visits at parity with in-person visits, to be shortly followed by the Centers for Medicare and Medicaid Services (CMS). Many of us have been clamoring for this evolution in coverage for years. But it took the extraordinary circumstances of the COVID pandemic for payers to see the validity of this measure to increase access for patients while appropriately reimbursing providers. Just as surprisingly, BCBS NC also announced they were waiving cost-sharing for COVID-related diagnosis and treatment. Could this be an acknowledgement on the part of payers that cost-sharing limits access to care? And will that ultimately translate into cost-sharing reductions for chronic illnesses like cancer? I’m not overly optimistic, but watch this space.

Where Do We Go From Here?

As oncologists, we must capitalize on this momentum to make lasting changes in the way we care for patients with cancer. Today, what we have is a “nodal” model of care, in which patient are evaluated every few weeks at the start of each treatment cycle. In between nodes, when patients are at their sickest and home alone, is when they are in greatest need of care and most likely to end up in the emergency department.

Graph showing three curves related to outcomes from the COVID pandemic: mortality from the disease, delay/interruption in care, and economic trauma/burnout. Image adapted from Victor Tseng, Emory University.
Adapted from Victor Tseng, Emory University

This is what we have. But what we need is a continuous care model in which patients are virtually evaluated by telehealth and through electronic patient-reported outcomes. Data from these tools can serve as canaries in the coal mine, helping to identify patients at greatest risk for getting sick. However, as we consider how to implement these changes long-term, we can’t overlook the possibility that interventions such as telehealth might actually worsen access and outcome disparities for some underserved and particularly vulnerable patients—a topic my colleague Dr. Lola Fayanju has written about eloquently.

We must also carefully watch the curves—and not the one we think of most. Over the past few weeks, we have been most focused on the COVID-19 infection curve (in red). At least here in North Carolina, we hope we are just past the peak. However, two other curves warrant careful monitoring, and neither have reached their peak here or globally. I believe we are yet to see the health impact of delayed and deferred care and diagnosis of patients with chronic illnesses such as cancer (orange curve), something Dr. Fayanju has also written about in detail. That peak is likely a few months or a year away. We must watch for the lingering toll of emotional trauma, economic fallout, and provider burnout. Unfortunately, that peak may be years in the making.

Patient outcomes, practice patterns, research, and policy usually shift incrementally over years. Over the past few weeks, we have seen dramatic new developments in these domains related to cancer.

Still, I can’t help but be struck by the fact that despite enormous efforts expended in advocacy, lobbying, and infrastructure investments, for us see real change in cancer care delivery, it takes a major public health crisis. Hopefully, we will learn something from these changes, at least some of which may prove beneficial to patients.

Read more blog posts by Yousuf Zafar, MD, MHS