Patients with cancer are on heightened alert for COVID-19. Should they get infected, they are five times as likely to die (7.6%) than patients who have COVID-19 but no comorbid conditions, according to a report from the World Health Organization.
Despite this threat, cancer doesn't stop for a pandemic. For many patients, the disease they already have is a greater danger than a disease they might get. While there may be scenarios in which cancer-related therapies, studies and routine visits could be safely postponed for several months until the pandemic subsides, for many patients delaying therapy is a life-and-death issue.
The tension has led oncologists and their patients to grapple with a new risk environment: When cancer therapy cannot be delayed, how can we minimize patients' risk of exposure, and do so without compromising on the quality of care?
In our work with both health plan partners and oncology practices since the COVID-19 threat emerged, we've identified several approaches that can help them strike this balance.
Change the Physical Environment of the Practice
Oncology practices have quickly responded to the pandemic with common-sense changes to their physical environment to prevent coronavirus transmission to patients and clinicians. Not permitting family members to attend visits, checking in patients from their cars, separating infusion chairs and waiting room chairs by six feet or more, are examples. Depending on a specific individual's situation, physicians could use telemedicine encounters to replace some face-to-face visits, and virtual support groups could stand in for the groups that practices often host in person. Some patients' lab specimens could be collected at home.
Enact Utilization Management Policies that Support Fewer Visits
Health plans could ease prior authorization requirements to allow the use of therapies that could minimize patient visits to practices. Myeloid growth factors, which patients receive after chemotherapy to rebuild white blood cells, represent one of the larger opportunities that could possibly reduce visits. While a short-acting growth factor is less expensive—and therefore preferred by health plans—it typically requires patients to return to practices for five to 10 consecutive days following chemotherapy. Long-acting growth factor could be administered the day after or even the same day as chemotherapy, possibly eliminating some return visits. When the COVID-19 crisis hit, we reached out to health plans to ask them to allow long-acting growth factor as a preferred drug during the pandemic, and they agreed.
Other areas where we've worked with health plans to reduce visits, depending on an individual's specific situation, include:
Supporting oral medications that can be taken at home, for the small percentage of cancers where that is an option.
Approving shortened radiation therapy courses that are backed by evidence to be highly efficacious.
Waiving requirements for imaging studies to assess response to therapy before administering additional rounds of treatment. However, these studies should continue, whenever prudent, to ensure the therapy is benefiting the patient.
Implement Patient Triage Protocols
Pandemic or not, patients undergoing cancer therapies may experience complications, such as nausea and diarrhea, and call seeking advice on what to do about them. A nurse triage tool could standardize the response, to help patients not come into the clinic or emergency department unless it's necessary. In some cases, the oncologist could adjust the medication regimen or call in a new drug to alleviate the symptoms to avoid a patient visit.
Protect Practice Viability
Many oncology practices are reporting significant drops in face-to-face visits in the pandemic. As they seek to do what's right by their patients, the practices may be suffering financially. We are advocating for up-front capitated payments or other payment models that could help practices weather the crisis, while rewarding them for clinical decisions that reduce coronavirus exposure. Extending authorizations for treatment and removing referral requirements may also reduce the administrative burden on stressed practices.
Delay Therapy When It's a Safe Option
In specific scenarios, chemotherapy could be delayed for several months until the pandemic subsides. Depending on case-by-case physician evaluations, these patients could include some who are in deep remission receiving maintenance therapy and those with chronic malignancies that are relatively stable, such as multiple myeloma. Some adjuvant therapies could also be delayed, when the benefit of this chemotherapy is small and where there are options available that are not immunosuppressive. Any chemotherapy or therapy that may be able to be delayed is a decision made by each individual's doctor on a case-by-case basis.
Just as cancer care should be personalized, decisions about treatment plans in this pandemic are based on individual patient cases and local circumstances, including the prevalence of COVID-19 in the patient's community. Additionally, expert panels and professional societies are rapidly issuing new guidance for treating cancer during the pandemic—taking weeks to complete a process that normally takes years. For example, an international panel of oncologists recently recommended shortening radiation therapy for rectal cancer from five weeks to one week of higher-intensity treatments, while safely delaying surgery for up to 12 weeks. As such guidance reshapes the treatment landscape, oncologists and health plans will need to be flexible and resilient—displaying the same characteristics that will help get us all through this crisis.
About the AuthorFollow on Linkedin More Content by Andrew Hertler, MD, FACP