By CHADI NABHAN MD, MBA, FACP
One harsh Chicago winter, I remember calling a patient to cancel his appointment because we had deemed it too risky for patients to come in for routine visits—a major snowstorm made us rethink all non-essential appointments. Mr. Z was scheduled for his 3-month follow-up for an aggressive brain lymphoma that was diagnosed the prior year, during which he endured several rounds of intense chemotherapy. His discontent in hearing that his appointment was canceled was palpable; he confessed that he was very much looking forward to the visit so that he could greet the nurses, front-desk staff, and ask me how I was doing. My carefully crafted script explaining that his visit was “non-essential” and “postponable” fell on deaf ears. I was unprepared to hear Mr. Z question: if this is his care, shouldn’t he be the one to decide what’s essential and what’s not?
This is a question we are all grappling with in the face of the COVID-19 pandemic. The healthcare industry is struggling to decide how to handle patient visits to doctor’s offices, hospitals, and imaging centers, among others. Elective surgeries are being canceled and advocates are arguing that non-essential outpatient and ER visits should be stopped. Ideas are flying left and right on how best to triage patients in need. Everyone has an opinion, including those who ironically consider themselves non-opinionated.
As an oncologist, these various views, sentiments, tweets, and posts give me pause. I understand the rationale to minimize patients’ exposure and thus prevent transmission. However, reconsidering what we should deem “essential” has made me reflect broadly on our method of providing care. Suddenly, physicians are becoming less concerned about (and constrained by) guidelines and requirements. Learning how to practice “essential oncology” may leave lasting changes in our field.
I may not be an authority on deciding what’s an elective versus non-elective surgery, but I will take a stand and offer some of my thoughts on the current state and what might await us as oncologists in the post-COVID-19 era. Before I offer my opinions on essential oncology, I thought I should ensure that my definition of “essential” matches that of others. Assuming that some patients might have already done so, I Googled the term and found that Oxford defines “essential” as “a thing that is absolutely necessary,” while Merriam Webster’s definition of “essential” is “something necessary, indispensable, or unavoidable.” Neither definition infers perspective, but we can all agree that what’s deemed necessary is in the eyes of the beholder. As such, in tackling this pandemic, oncologists are having to take a long, hard look at what care is necessary to provide and which guidelines are necessary to follow.
First off, some are questioning our current dosing schedules of chemotherapy, including the novel ones such as checkpoint inhibitors. Why not give that chemo drug every 4 weeks instead of every 2 weeks? Maybe we should give nivolumab every 6 weeks? Let’s lower the dose of pembrolizumab and skip a few days of venetoclax. Opinions vary, but the concept is the same: let’s give less chemo because suddenly COVID-19 is riskier than cancer. If our dose modification schemes change (most of which were not based on real basic science or pharmacology) this might throw all our regimens in shambles. If outcomes are not adversely affected, do we go back to our routine dosing and scheduling, or do we maintain the novel COVID-19 approach to chemotherapy? You tell me.
Next, my inbox has been flooded with invitations to attend webinars and virtual meetings on how best to manage patients during COVID-19 and how to balance risks and benefits, as if such balance should never exist outside of a pandemic. Never have I seen the oncology community engage in more debates about the risk/benefit ratio of chemotherapy in late-stage metastatic incurable malignancies. Suddenly, physicians who had been advocating 4th line chemotherapy for a metastatic cancer where data were marginal became loud voices encouraging stopping chemotherapy and offering only palliative care. It took the COVID-19 pandemic for the oncology community to look at itself in the mirror and ask whether chemotherapy should be given in end-stage disease. This may be the only real benefit of COVID-19.
Furthermore, it has been proposed that adjuvant therapies can sometimes be delayed and that some drugs should be avoided. Many have argued that stem cell transplantation should be deferred until we are over the COVID-19 hump. I am certain that there will be studies in the years to come (I even might do one if I’m not too busy tweeting) on whether delays in adjuvant therapies for some cancers had any detrimental effect on outcomes. How would that affect guidelines, recommendations, and future care? Stay tuned; there will be so many papers on this and little time for peer-reviews.
Fourth, how we approach imaging in determining progression-free survival may entirely change. Typically, scans are needed every 6-8 weeks to determine a response to therapy and allow a decision on whether to continue or stop the treatment. I don’t want to bore you with the RECIST criteria (and trust me, it’s boring), but it’s what radiologists use when helping oncologists determine if an anti-cancer therapy is working or not when treating solid tumors. Thanks to COVID-19, oncologists now have to make these decisions based on how patients feel and their perception of whether the drug is providing a clinical benefit. It should have been this way before COVID-19, but it wasn’t. We were so blinded by RECIST that we sometimes missed the larger picture. Could COVID-19 be the death sentence to RECIST? Will we find out that we were overutilizing our scanners? Could COVID-19 lead to saving future healthcare costs when some of these guidelines change? Maybe.
Fifth, follow-up visits for cured patients or those in remission have always been—and should continue to be—considered an essential component of routine care. It might be in the not-so-distant future when hospital administrators decide that some kinds of patient visits need to be conducted virtually. However, the rapport and bond established between a patient and his/her physician extends beyond the duration of chemotherapy administration. Patients need the reassurance that their disease remains at bay. The positive energy from these visits is also welcomed by oncologists as a break from cases where patients are less fortunate and a reminder that patients do get cured. Stripping oncologists and our patients of this right to face-to-face routine visits seems cruel. For now, we can all endure deferring these appointments or transitioning to telemedicine for the greater good, but I fear that this might extend beyond COVID-19. While I agree that virtual visits can save time and money, most would concur that nothing replaces human-to-human interaction—especially now, when we’re all feeling the effects of social distancing. Remembering how important Mr. Z’s follow-up appointment was, I dread the day when hospitals consider converting these routine visits to virtual ones so that new patients can be accommodated.
Finally, will COVID-19 teach us how to better conduct clinical trials? Every oncologist understands the value of clinical trials and how they advance science and help patients. But trials are strictly regulated. Labs have to be drawn within X and Y times, scans must be done within X-days from subsequent therapy, and face-to-face visits are a must. Dispensing an investigational drug requires several staff members present and a verification process that is critical, but sometimes unnecessarily complicated. Now that clinical trials have taken a hit, will this pandemic teach CROs that 700 signatures on an adverse event sheet might not be needed? Would potential changes give patients more sense of autonomy when they are participating in these studies? I predict that if we apply the lessons learned from COVID-19 on how we conduct studies, enrollment in oncology trials will increase. But this means that all of us, including CROs, need to do things differently.
It has taken a pandemic and a relentless virus to get the medical community to think critically about our own behavior and the care that we provide. We will overcome this at some point, and although we will all remember the horror of COVID-19, maybe we can find a silver lining in camaraderie and in adjusting some of the ways we provide oncology care. Until then, please stay home.
Chadi Nabhan ( @chadinabhan) is a hematologist and oncologist in Chicago whose interests include lymphomas, healthcare delivery, strategy, and business of healthcare.