GU oncologist's perspective: pandemic poses unique challenges in vulnerable patients

The coronavirus disease 2019 (COVID-19) pandemic has dramatically transformed health care delivery around the globe. In several months, nearly every component of health care

Rana R. McKay, MD

has been altered as the medical community faces the challenge of continuing to deliver quality care while mitigating risk of the severe acute respiratory syndrome coronavirus 2.

Cancer care has a unique challenge given the need to continue to provide effective treatment while balancing the risk of COVID-19 in a vulnerable patient population. Individuals with cancer are particularly susceptible to the negative consequences of COVID-191-4 given frequent touch points with the health system, immunosuppressive effects of treatments, and the underlying malignancy itself, which can potentially impact viral transmission and pathogenesis. Additionally, patients may be older and have contributing comorbidities that can amplify the risk of COVID-19–related complications.

During this unprecedented time, oncology teams have been propelled to develop new operational models for care delivery. One of the most immediate and dramatic alterations has been the widespread adoption of telehealth services. Although the technology is not new, barriers to implementation have historically included ingrained culture and reimbursement challenges. Telehealth services have facilitated the recommendation for physical distancing to curtail the spread of the virus. As we implement telehealth services, it is critical to establish early best practices for integration of translator services, conducting informed consent, and incorporating support for individuals with fewer resources.

While we are catapulted into this innovative technology age, caution must be taken to continue to protect the interface between patients and clinicians that serves as the core of the practice of medicine. Preserving the art of doctoring, as established by Sir William Osler, will safeguard against the dilution of clinical skills and burnout.

Additional measures have been invariably implemented across oncology practices with the goal of mitigating risk while continuing to provide essential care for patients. These approaches include screening procedures to identify and triage persons with presumptive COVID-19 disease, restrictive visitor policy to decrease foot traffic throughout medical facilities, and use of personal protective equipment (although this has been limited by insufficient supply in many settings).

Additionally, screening with polymerase chain reaction testing of asymptomatic patients, particularly those undergoing a procedure, having surgery, or receiving infusional treatment and also screening of asymptomatic health care workers is being performed as availability of testing increases. Rapid point-of-care tests to accelerate clinical decision-making and decrease burden on centralized laboratories are critically needed, especially as patients continue to receive oncologic care.

The COVID-19 pandemic presents a unique set of challenges for clinicians caring for individuals with genitourinary malignancies. Clinicians have responded to the pandemic by adapting patient care to minimize COVID-19 exposure risk and preserve health care resources. Current preliminary guidelines for disease management are based on expert opinion and indirect scientific evidence given lack of robust data to guide clinical decision-making.5 Factors influencing treatment recommendations include (1) goals of therapy (curative, palliative, or supportive intent), (2) disease context (neoadjuvant, adjuvant, recurrent, or metastatic), (3) mode of treatment delivery (oral, injection, infusion), and (4) toxicity profile associated with therapy (myelosuppression, pulmonary toxicity, risk of hospitalization, and others).

As the pandemic evolves and our understanding of factors that impact risk expand, recommendations will adapt to optimize treatments for patients with genitourinary malignancies. Given the unprecedented context of the COVID-19 pandemic, the long-term consequences of alterations in care, particularly regarding cancer-related outcomes, remain unknown.

Management of genitourinary malignancies requires a highly integrated and multidisciplinary approach. It is critical that readiness measures and risk mitigation strategies continue to include multidisciplinary discussions. Continued virtual tumor boards incorporating urology, medical oncology, radiation oncology, pathology, and radiology can enhance clinical decision-making and individualize care for patients in the context of institutional policies. Additionally, developing management recommendations based on local and regional pandemic severity will be critical to ensure the best outcomes for patients.

An essential component of urologic oncology is facilitating advanced care planning and providing end-of-life care for patients with terminal malignancies. Developing a proactive and coordinated approach with other members of the care team, including palliative care and social work, will be necessary for medico-ethical decision-making based on patient wishes and preferences. Preserving compassion and avoiding care disparities at the end of life has never been more important.

Access to clinical trials is a core component of the care of patients with genitourinary malignancies. Although clinical trials may provide opportunities for patients, involvement will likely be on a case-by-case basis, depending on a multitude of factors. The FDA has outlined considerations to ensure the safety of trial participants, maintain compliance with good clinical practice, and minimize the risks of trial integrity.6 Health systems have fully focused on responding to the crisis, in parallel to clinical research efforts, but basic and translational research has been substantially scaled down.

It is still too early to determine the long-term impact of the pandemic on future research. However, it is becoming increasingly evident that scientists need to adapt and develop new ways to continue to innovate.

Granular longitudinal data are needed

As a field that is largely driven by evidence-based medicine, the oncology community needs better data to inform clinical decisions and guide clinical practice recommendations. Working together to share best practices will be critical as we recover from the pandemic. Additionally, granular longitudinal data will be needed to develop guidelines to protect patients and the community. The COVID-19 and Cancer Consortium developed as a grassroots initiative with the mission to rapidly collect and disseminate information about cancer and COVID-19 (www.ccc19.org). The COVID-19 and Cancer Consortium registry collects information from patients who test positive for severe acute respiratory syndrome coronavirus 2 (or those who are presumed positive for COVID-19) with all cancer types. Other multi-institutional registries established by the American Society of Clinical Oncology, American Society of Hematology, and National Cancer Institute are also established with a unified mission to help the oncology community learn more about patterns of presentation of COVID-19 in patients with cancer, COVID-19 transmission and complications, and impact of COVID-19 on cancer care delivery and outcomes.

As the medical system looks ahead to the recovery phases of the COVID-19 pandemic, it is likely that new strategies will need to be implemented to ensure the continued safety of patients and health care workers. As practicing clinicians, it is essential that we continue to meet the needs of our patients and deliver safe, high-quality care.

McKay is assistant professor of medicine at the Moores Cancer Center at the University of California San Diego, La Jolla, California.

References

1. Zhang L, Zhu F, Xie L, et al. Clinical characteristics of COVID-19-infected cancer patients: a retrospective case study in three hospitals within Wuhan, China. Ann Oncol. 2020. Mar 26;S0923-7534(20)36383-3. doi: 10.1016/j.annonc.2020.03.296 Online ahead of print.

2. Mehta V, Goel S, Kabarriti R, et al. Case fatality rate of cancer patients with COVID-19 in a New York hospital system. Cancer Discov. 2020. May 1;CD-20-0516.doi: 10.1158/2159-8290.CD-20-0516 Online ahead of print.

3. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21(3):335-337. doi: 10.1016/S1470-2045(20)30096-6

4. Dai M, Liu D, Liu M, et al. Patients with cancer appear more vulnerable to SARS-COV-2: a multicenter study during the COVID-19 outbreak. Cancer Discov. 2020 Apr 28.doi: 10.1158/2159-8290.CD-20-0422 Online ahead of print.

5. Wallis CJD, Novara G, Marandino L, et al. Risks from deferring treatment for genitourinary cancers: a collaborative review to aid triage and management during the COVID-19 pandemic. Eur Urol. 2020. May 3;S0302-2838(20)30331-6. doi: 10.1016/j.eururo.2020.04.063 Online ahead of print.

6. FDA guidance on conduct of clinical trials of medical products during COVID-19 public health emergency. US Food and Drug Administration. March 2020. Accessed May 19, 2020. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/fda-guidance-conduct-clinical-trials-medical-products-during-covid-19-public-health-emergency.