COMMENTARY

COVID-19 Diary Day 10: So Many Questions, No Answers

Don S. Dizon, MD

Disclosures

April 17, 2020

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Today I made my way through our empty clinic and into the back, where I sat with my team. Scanning my schedule, I saw two 1-hour visits: people with a new cancer diagnosis.

Don S. Dizon, MD

Cancer never got the COVID-19 memo. It wasn't following any stay-at-home orders; it was still disrupting people's lives, as ever, and my role in helping them make sense of this life-changing diagnosis wasn't stopping either.

Since coming to Lifespan Cancer Institute, I've taken on a new program as lead medical oncologist for sarcoma. Fortunately, I have a great mentor in Brad DeNardo, MD, a pediatric oncologist who specializes in it, particularly in the adolescent and young adult population. Together we started a sarcoma multidisciplinary clinic and we see patients together once a month. Today we had several with sarcoma to see together; one was a person who had undergone a very complicated surgery and was recovering in a nursing home.

I became momentarily alarmed. In Rhode Island, as in other areas, nursing homes and other group settings are high-risk areas for infection, and most of our COVID-19 deaths were happening in this highly vulnerable segment of our population.

I worried that this patient might have it. Even if he had no symptoms, we could not rule out that he was an asymptomatic carrier. Still, we weren't about to cancel the appointment. I alerted my team that our new patient would be coming from a nursing home and that we all would need to protect ourselves.

Our standard has been to wear a surgical mask, but I wondered whether Brad and I needed more. Shouldn't we have personal protective equipment (PPE) in order to conduct the visit?

Like many institutions, however, we too are rationing PPE to areas where they were most needed, especially for staff involved in "aerosol-generating" procedures like intubation, where the risk for infection is greatly increased.

Fortunately, the cancer institute has its own supply of PPE, and after one inquiry we were provided with it for this visit, though not without caveats. "There are gowns, gloves, face shields, and surgical masks," our stellar medical assistant informed us. "The face shield you will need to keep safe—it's the only one you will get."

All of a sudden I felt as if I was holding onto something more precious than gold. But I was also struck by how strange that was to hear. Sounding a lot like my mother, I replied, "I remember practicing when you used the face shield once and then disposed of it." We both looked at each other and chuckled, knowing that this had been the state of affairs not 10 years ago but just 2 months ago.

Gowned and gloved, we went in to see the patient. In normal circumstances, Brad or I would sit close by him, asking what he knew about his diagnosis. Then we would carefully explain the difference between grade and stage, the role of medical treatments, and the importance of surgery. I'd lean in to speak intimately about his prognosis, and if needed, gently place my hand on his shoulder as we spoke.

Now we stood 6 feet away, faces covered, and raised our voices to make sure we were heard through the layers of protection in front of us. Although our patient also wore a mask, his eyes conveyed fear—not of COVID-19 but of cancer.

We made a plan: no chemotherapy; we would repeat imaging in 2 or 3 months and see where we were. Hopefully by then he would be home and the pandemic would be past its peak. Afterwards, I put my mask in a plastic bag, labeled it with my name in big, bold letters, and set it away. I thought about locking it up in my cabinet, as if it were something of great value, but then I convinced myself that I was overreacting. After all, it's not like it was brand new!

Later that day I met with someone whom I've treated for the better part of a year. She had an aggressive tumor, one that I thought she wouldn't survive. But after several months of chemotherapy, she had successful surgery and was in the middle of adjuvant treatment when COVID-19 became an issue. Her regimen called for admission to the hospital. At the time, we had talked about the pros and cons of continuing treatment versus not. Despite the risk for infection, we were more scared of relapse, so we decided to complete it.

We were reviewing the details of her next admission when I realized that due to a change in policies, she needed COVID-19 testing before admission. She completely understood, asking, "Can I get tested today?"

I didn't know. Our evolving policy required testing no more than 24 hours before a planned admission, whether someone had symptoms or not, so there would be no testing today. We made arrangements for her to return at a designated time for rapid screening. But I asked myself, what happens then?

If she tests negative, the admission would obviously proceed. But what if she tests positive? She would not be admitted to our inpatient cancer service; instead, she would either be admitted to a COVID-19–positive floor or would need to go home and quarantine. In either case, would treatment be delayed? And because she was asymptomatic, couldn't she get her chemotherapy, which was being given to cure her of cancer?

I didn't think so. It sure didn't sound like administering chemotherapy to someone with COVID-19 was a good idea. But by not proceeding with treatment, we could be reducing her chance of cure. Would she have the choice to proceed or not? There were so many questions and no answers.

"Well, let's get you tested, because we need to," I told her. "For now, I'll assume that the test is negative, and we will proceed exactly as we planned, okay?"

"Okay," she said.

She asked no other questions and I volunteered no further guidance. I know that one of my roles in the lives of my patients is to provide hope, and this is what I wanted her to have, right now. I can only hope that I'm right.

Don S. Dizon, MD, is an oncologist who specializes in women's cancers. He is the director of women's cancers at Lifespan Cancer Institute and director of medical oncology at Rhode Island Hospital.

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