Cancer Care Innovation During the COVID-19 Pandemic
Fatinah Albeez, Princeton University
What is Cancer-Care?
Cancer-care is the care of patients with cancer, both in terms of chemotherapy and drug therapy trials for treatment purposes and symptom-management purposes (particularly for those patients whose conditions are incurable or who choose to not pursue treatment options). In terms of both patients undergoing treatment and those who forego it, cancer diagnoses often involve many Emergency Department visits to treat symptomatic conditions that need to be addressed regularly. Ultimately, repeated hospital visits cause patients to incur great sums in hospital bills and greatly diminishes their quality of life within the first year of diagnosis.1 In terms of both patients undergoing treatment and those who forego it, cancer diagnoses often involve many Emergency Department visits to treat symptomatic conditions that need to be addressed regularly. Within one year of being diagnosed, 75% of patients with advanced stages of cancer are hospitalized, with one of every six patients in this cohort being hospitalized three or more times.1 Ultimately, repeated hospital visits cause patients to incur great sums in hospital bills and quality of life diminishes greatly within the first year of diagnosis.1 Not only does Medicare spend approximately “$30 billion on beneficiaries with cancer in their first year of diagnosis,” but many patients also are faced with remarkably large “out-of-pocket” costs.1 Furthermore, cancer care is unlike post-op or dialysis-type procedures since patients’ mental well-being is given equal priority as their physical state. Given the psychological and psychosocial components of healing, oncologists create treatment plans with their patients with the aim of maximizing their quality of life. Health psychology studies have shown that cancer patients who undergo treatment with family and friends as a part of their support system show positive reactions to treatment sooner and with great progress. Isolation, on the other hand, since the pandemic has caused patients to be in treatment alone since due to Covid, family members cannot stay with the patient at the hospital. Needless to say, cancer patients undergoing treatment alone demonstrate poorer reception to drug therapies and experience depression.2 Cancer patients are also severely immunocompromised due to chemotherapy and other drug/radiation therapies and are prone to getting Covid-19 either at the hospital itself or at home.3 During the pandemic, these patients who comprise a large portion of the immunocompromised population in the United States are reluctant to make visits to the emergency department in fear of being at high risk for catching Covid-19.4 Ultimately, the pre-pandemic healthcare system’s emphasis on clinic or hospital-based treatment models led to the lack of preparedness for administering cancer-care to cancer patients in the Covid-19 pandemic.
Why is investing in Cancer-Care Innovation Imperative Now?
The global decrease in the number of cancer diagnoses since the onset of the pandemic is alarming and cannot be erroneously attributed to an effect of Covid-19 safety measures such as increased mask-wearing and social distancing. Unlike influenza, cancer is neither airborne nor viral. John DeRosier reports in Hem Onc Today that the mean weekly number of newly identified patients with six common cancer types was 4,310 from January 6, 2019 through February 29, 2020 but 2,310 at the peak of the pandemic from March 1, 2020 through April 18, 2020.5 Epic Health Research Network reported a deficit of 63-67% of screenings for breast, colon, and cervical cancers relative to the number of screenings that would have been done pre-pandemic.6 Backlog in routine physical examinations and repeat screenings are especially dangerous for cancers that have a high risk of metastasis.7 Furthermore, Covid-19 killed more people worldwide at the peak of the pandemic than any other leading cause of death.8 According to Eurostat, in Europe, there were 12.95 daily deaths due to Covid-19 per million population which was nearly double the 7.08 daily deaths due to cancer per million population.9 Though this most certainly reflects the great mortality of Covid-19, given that a study by Cancer Research UK cited in Lancet Oncology found that nearly “45% of those with potential cancer symptoms did not contact their doctor” during March through August 2020 due to fear of becoming infected with Covid-1910, it is extremely likely that the statistic of 7.08 daily deaths per million due to cancer is not representative of the actual number of daily deaths due to cancer in Europe. This is alarming because annual cancer mortality rates have been used over the past decade to evaluate whether population-wide decreases in smoking, for example, have been effective and statistically significant in lowering cancer mortality rates.11 Without accurate cancer mortality rates and decreased rates of cancer screenings done and cancer diagnoses made, senior medical director at Quest Diagnostics Dr. Harvey Kaufman writes, “The delay in diagnosis will likely lead to presentation at more advanced stages and poorer clinical outcomes.”12 Although the specific effects of late diagnosis of cancer in patients due to Covid-19 remain unknown, diagnosing cancers in advanced stages has been linked to increased mortality.13,14 It is imperative that we prepare our hospitals and healthcare systems for the surge in cancer diagnoses and screenings post-Covid. Ultimately, investing in cancer-care innovation at present will allow for hospital-based resources to be made available for the influx of cancer patients post-Covid.
Revolutionizing Cancer-Care At-Home: University of Pennsylvania Center for Cancer-Care Innovation
In February 2020, Dr. Justin Bekelman launched “Cancer Care @Home” through the University of Pennsylvania’s Center for Cancer Care Innovation (PC3I). The program allows for patients to have infused or injected drug therapies from the comfort of their homes, saving them the risky trip of visiting hospitals in the midst of the pandemic. According to Joan Doyle, executive director of Penn Medicine’s home care and hospice service, “Before the current COVID-19 pandemic, about 1,850 patients were getting their infusions at home per day, and that up to almost 2,000” in April 2020.15 The program’s timely launch made it possible for its expansion to be accelerated during the pandemic when burdens placed on the hospital systems by Covid-19 rendered resources unavailable to meet the treatment requirements of cancer patients.16 In an interview with The ASCO (American Society of Clinical Oncology) Post, Dr. Bekelman says that a crucial component of planning the Cancer-Care At-Home Program was breaking down barriers to home cancer care.17 He explains that “treating oncologists order the cancer drugs, which are administered by Penn Home Infusion Therapy nurses, who have been certified by the Oncology Nursing Society.”16 The safety and quality protocols of home injections and home infusions matched those observed in the hospital and clinic facilities.16 In terms of theeconomic feasibility and accessibility of the program, Dr. Bekelman explains that the out-of-pocket costs patients incur depend on their insurance type and urges insurance providers (Medicare, Medicaid, and commercial insurance companies) “to develop new rules to help patients pay for at-home cancer care.” 17 He follows that insurance policies need to be more patient-centric and incentivize “innovation in the delivery of cancer care” since these patients are immunocompromised and decreasing the density of chemotherapy and infusion centers will reduce cancer patients’ risk of infection and increase hospital capacities.17 While PC3I is working to expand the program to other hospitals in the Philly, NYC, and Jersey areas, another key element of research being conducted at PC3I is to increase the number of drug therapies that can be conducted via injection to these patients.18
What does the Cancer-Care At-Home Program Implicate for the Future of Healthcare?
University of Pennsylvania’s Cancer-Care At-Home Program is a model for cancer-care innovation across the United States. At its core, PC3I’s Program is an expansion of Johns Hopkins’ Hospital at Home Program, which indicates that Tele-Health programs have been in demand since the early 2000s. However, critiques of tele-health from both physicians and patients’ worries that the patient-physician interaction is severely altered due to an inability to share empathy and emotions through a screen in addition to privacy concerns as to whether a patient is able to share pertinent information with the physician that they would be able to in a clinical setting.19 Furthermore, in the past, the use of telehealth is lowest in patients over the age of 65 years old and in patients of Black and Hispanic origin. Thus, the expansion of Cancer-Care At-Home Programs across the United States must be accompanied with equitable access to digital assistance, language interpretation, secure WiFi connectivity, and hardware to access Telehealth platforms. While the Covid-19 pandemic has shown us that at home programs are possible and can reduce the burdens of the hospital systems, freeing up resources to be used elsewhere, it is imperative that cancer-care at-home programs keep equitable access to at-home cancer care at the center of their patient-centric mission.
Conclusion
Furthermore, the uniqueness of cancer-care is that the goal is for the patient to be the most comfortable as possible, thereby giving priority to the patient's mental wellbeing throughout the duration of the treatment. This makes the PC3I’s Cancer-Care At-Home Program an ideal program to expand to each state as the healthcare industry negotiates with commercial insurers to reevaluate policies to increase affordability of telemedicine by decreasing patients’ out-of-pocket costs. Current telemedicine policies vary by state with certain states barring providers from engaging in telemedicine video visits with patients in other states.20 Thus, accelerated yet equitable expansion of cancer-care at-home programs will enable our healthcare system to not be overwhelmed by the rise in cancer diagnoses and necessary screenings post-Covid. In conclusion, the crux of global pandemic preparedness comes from reducing the burdens from our healthcare systems to ensure our hospitals operate under capacity such that resources remain available in times of crisis.
Works Cited
1 Cancer Care @ Home—PC3I. (n.d.). Retrieved April 25, 2021, from https://www.pc3i.upenn.edu/projects/cancer-care-at-home-program/
2 Feelings of oncology patients about being nursed in protective isolation as a consequence of cancer chemotherapy treatment—PubMed. (n.d.). Retrieved April 26, 2021, fromhttps://pubmed.ncbi.nlm.nih.gov/10457247/
3 I Had Breast Cancer and the Coronavirus at the Same Time. (n.d.). Retrieved April 25, 2021, fromhttps://www.oprahdaily.com/life/health/a34240368/breast-cancer-coronavirus/
4 Will COVID-19 Cause a Surge in Cancer Cases? (n.d.). Moffitt Cancer Center. Retrieved April 26, 2021, from https://moffitt.org/endeavor/archive/will-covid-19-cause-a-surge-in-cancer-cases/
5 Sharp declines in new cancer diagnoses observed during COVID-19 pandemic. (n.d.). Retrieved April 25, 2021, from https://www.healio.com/news/hematology-oncology/20201001/sharp-declines-in-new-cancer-diagnoses-observed-during-covid19-pandemic
6 MD, C. M., & PhD, A. M. del R. (n.d.). Delayed Cancer Screenings—A Second Look. Epic Health Research Network. Retrieved April 25, 2021, from https://ehrn.org/articles/delayed-cancer-screenings-a-second-look
7 The Pandemic Is Delaying Cancer Screenings and Detection—Scientific American. (n.d.). Retrieved April 25, 2021, fromhttps://www.scientificamerican.com/article/the-pandemic-is-delaying-cancer-screenings-and-detection/
8 Sharp declines in new cancer diagnoses observed during COVID-19 pandemic. (n.d.). Retrieved April 25, 2021, from https://www.healio.com/news/hematology-oncology/20201001/sharp-declines-in-new-cancer-diagnoses-observed-during-covid19-pandemic
9 How lethal is COVID-19 compared to cancer, accidents, flu and other causes? (n.d.). Retrieved April 25, 2021, from https://newseu.cgtn.com/news/2020-09-26/How-lethal-is-COVID-19-compared-to-cancer-flu-and-other-death-causes--U4LJxzQlA4/index.html
10 Oncology, T. L. (2021). COVID-19 and cancer: 1 year on. The Lancet Oncology, 22(4), 411. https://doi.org/10.1016/S1470-2045(21)00148-0
11 Understanding Cancer Death Rates. (n.d.). Retrieved April 25, 2021, from https://www.cancer.org/latest-news/understanding-cancer-death-rates.html
12 Sharp declines in new cancer diagnoses observed during COVID-19 pandemic. (n.d.). Retrieved April 25, 2021, from https://www.healio.com/news/hematology-oncology/20201001/sharp-declines-in-new-cancer-diagnoses-observed-during-covid19-pandemic
13 Will COVID-19 Cause a Surge in Cancer Cases? (n.d.). Moffitt Cancer Center. Retrieved April 26, 2021, from https://moffitt.org/endeavor/archive/will-covid-19-cause-a-surge-in-cancer-cases/
14 The Pandemic Is Delaying Cancer Screenings and Detection—Scientific American. (n.d.). Retrieved April 25, 2021, fromhttps://www.scientificamerican.com/article/the-pandemic-is-delaying-cancer-screenings-and-detection/
15 Penn, Jefferson expand at-home cancer treatments during COVID-19 pandemic. (n.d.). WHYY. Retrieved April 25, 2021, from https://whyy.org/articles/penn-jefferson-expand-at-home-cancer-treatments-during-covid-19-pandemic/
16 I, L., BegleyMichael, DelaneyTimothy, ZinckLindsey, M, S., DoyleJoan, MehtaShivan, E, B., & A, S. (2020). Accelerating the Delivery of Cancer Care at Home During the Covid-19 Pandemic.NEJM Catalyst Innovations in Care Delivery. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0258
17 How the COVID-19 Pandemic Is Propelling the Delivery of Home Care for Patients With Cancer—The ASCO Post. (n.d.). Retrieved April 25, 2021, from https://ascopost.com/issues/may-25-2020/how-the-covid-19-pandemic-is-propelling-the-delivery-of-home-care-for-patients-with-cancer/
18 How the COVID-19 Pandemic Is Propelling the Delivery of Home Care for Patients With Cancer—The ASCO Post. (n.d.). Retrieved April 25, 2021, from https://ascopost.com/issues/may-25-2020/how-the-covid-19-pandemic-is-propelling-the-delivery-of-home-care-for-patients-with-cancer/
19 The Pitfalls of Telehealth—And How to Avoid Them. (n.d.). Retrieved April 25, 2021, from https://hbr.org/2020/11/the-pitfalls-of-telehealth-and-how-to-avoid-them
20 Providing Care Accross State Lines | AAAAI. (n.d.). The American Academy of Allergy, Asthma & Immunology. Retrieved April 26, 2021, from https://www.aaaai.org/practice-resources/running-your-practice/practice-management-resources/Telemedicine/state