Clinicians, Researchers Adjust to COVID Cancer Upheaval

John Whyte, MD, MPH; J. Leonard Lichtenfeld, MD, MACP


May 18, 2020

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  • The COVID-19 pandemic has caused a significant reduction in cancer screenings, which will cause an increase in the number of new cancer diagnoses.

  • An American Cancer Society survey found that 50% of laboratory researchers could not get into their labs during the pandemic, and the other 50% were severely restricted.

  • Protocols in clinical oncology studies are being adjusted because of the pandemic, but many researchers report that they are able to make changes without a negative impact on patients.

  • Providers of care for cancer patients need to decide which patients need to come in for screening, diagnosis, and treatment and which patients can wait.

This transcript has been edited for clarity.

John Whyte, MD, MPH: You're watching Coronavirus in Context. I'm Dr John Whyte, chief medical officer at WebMD. I'm joined today by Dr Len Lichtenfeld, deputy chief medical officer of the American Cancer Society. Dr Lichtenfeld, thanks for joining me.

J. Leonard Lichtenfeld, MD, MACP: My pleasure.

Whyte: We've been telling patients to stay away from the hospital, to not come in. And they have been staying away. I saw a report late last week that says 87% of mammograms are down, 90% of colonoscopies, and nearly 60% of [prostate-specific antigen] tests.

There's the belief that this decrease in screening can lead to 80,000 fewer cancer diagnoses. How concerned should we be about this?

Lichtenfeld: Obviously, whenever there's a change in a typical pattern, we all become very concerned—that's a given. Honestly, I am not surprised that we've seen those declines.

The American Cancer Society, among other organizations, told people at average risk not to get routine cancer screenings during this period of time, that the risk of going into a medical setting was higher than the benefit of the screening—again, emphasizing people at average risk.

There's also no question in my mind that as we come out of this, as we begin to get to whatever that new normal is, we're going to see a backlog of people who will go get screened. And we will have an increase, consequently, of patients who are diagnosed with cancer.

My biggest concern is really twofold. Number one, that people at highest risk get screened as appropriate—let's say someone with the BRCA test. That people with signs or symptoms that suggest they may have cancer—whether they have rectal bleeding, for example, or a breast lump—that they make sure they don't wait.

That's not screening; that's diagnosis. I think we'll work our way through this. But yes, there will be a delay. And we will find out how much of an impact it actually has had.

Whyte: The American Cancer Society put out a report recently that talked about clinical trials in cancer care, and the FDA has put out some guidance about how to minimize the number of blood draws that people need, tissue samples, etc.

But it's hard enough to get people to enroll in clinical trials. Do you think we're going to be moving to clinical trials in home? Should patients just say, "You know what, I'm not going to worry about it right now"?

But then it becomes 6 months, a year, and then all of a sudden we're not reaching recruitment, to an even worse degree than before.

Lichtenfeld: There, again, is no question that clinical trials have been impacted. Some that were supposed to start didn't start, and in some that did start, there have been problems getting the drugs to patients or continuing the treatment. So it's a major issue. We aren't really great in this country about getting people on clinical trials in the first place, so this disruption from the pandemic is not going to make that circumstance any better.

The research enterprise in general has been significantly impacted by COVID-19, on the clinical side, as we're talking about here with clinical trials, but also on the basic research side. We did a survey. About 50% of the investigators —at the time we did the survey— couldn't get into their labs. The other 50% were severely restricted. And the same goes for the clinical side as well.

So it will have an impact. And I know that organizations are trying to do workarounds to make sure that impact is limited. You mentioned clinical trials at home. Yes, they're trying to get the drugs to patients where they are, wherever that may be.

Also, let's not forget the people who used to travel to some of these major institutions for a particular drug who can't get there. So the story, unfortunately, is that I wish we had a better handle on the pulse of what's actually happening. We hear anecdotes, but we don't have much organized information. But I sincerely hope, along with you, I'm sure, that we get this back on track as soon as we possibly can.

Whyte: And how concerned should patients be when their protocols are adjusted? Maybe they were receiving an infusion and now they're receiving an oral medicine, a pill. You and I know that that can cause a lot of anxiety on the part of patients. What can we tell them? How can we help them?

Lichtenfeld: In every bad situation there is always some good news that comes out of it. First off, physicians, oncologists, and surgeons, or radiation oncologists at local levels, have gotten together to try to figure out what's best for patients under these circumstances.

But on a national level, we've seen reputable medical organizations come together and say what they think has to be done today and where the modifications can occur. So it's no longer happening in a vacuum.

When we first started, a lot of decisions were made on the fly—what we call ad hoc. But now it's getting back into an organization, and it's been fascinating to hear the experts on webinars who say, "We've taken a good look at this and we think we can do it this way instead of that way, and there won't be any harm. And by the way, there's research that suggests that what we're doing (with) these changes won't be a problem."

But yes, when you're a patient and you have cancer, and you want to be treated and you want to get the best treatment possible, any change is a problem.

There's one thing that I want to point out. It's going to be the healthcare we need, and it may not be the healthcare we want. But I know that every oncologist, particularly those involved in cancer care, are doing their utmost, doing their best to make sure the patients have the least inconvenience—and frankly, the least harm—from any of the adjustments that have to be made.

Whyte: What do cancer centers and hospitals need to start doing to help patients recognize, depending upon what's happened in their local community, that it's safe to come back in to the hospital?

To your point at the beginning, we told them it's not safe. We also didn't have enough equipment in terms of personal protection. But how do they know that maybe it's safe to consider that colonoscopy, even at average risk? Because we know that those are often delayed. We know it's time to get some blood draws. Blood draws are 90% down. Who's getting any type of blood test that's not COVID-related?

So, there is a communication issue. We told them it's not safe to come in. Now we're starting to say that it might be. Soon we'll be saying, under these circumstances, that they can come in. Let's be honest: That can be confusing to patients, and to patients with cancer, who are very anxious.

Lichtenfeld: John, there's no question. First off, let's understand that all of the communication surrounding this pandemic has been confusing. The general public has gotten so many mixed messages. One place does one thing, another place does another thing. Maybe there's equipment, maybe there's testing; no, there isn't. Everyone is confronted—including me you, and all of the medical community—by mixed messaging.

This is really going to put responsibility on the shoulders of the medical community in particular, when we're talking about healthcare—the medical community, the medical facilities, the medical institutions, the universities, the cancer centers. It's going to put a major responsibility on their shoulders to show the patients, the public, that they're taking every step possible to keep everyone safe in a difficult situation.

We're not going to go back to normal; there's not going to be a day. There actually were some predictions about what day that may be, for different parts of the country. That's gone. Each day is another day.

Medical facilities, doctors, patients, nurses, health professionals of every type have to make sure they make patient safety a priority and prioritize who has to come in earliest, who does need that blood draw now, and who can wait.

Instead of a colonoscopy, maybe this year it can be a stool test for blood. Maybe that's what we do. Maybe you don't need a mammogram every year. Maybe if you're 60 years old and at average risk, you can get it every 2 years. The American Cancer Society says that's okay, as do other organizations.

Whyte: But as you know, patients often don't know whether they're at average risk or not. There's a lot of misunderstanding about that. And certainly to your point early on, if people are having symptoms, they feel a lump, they have bleeding, they have a mole that is rapidly changing, that's not screening. In some ways, that requires something different.

So we have to make sure we give patients good information too. What advice would you and the American Cancer Society give, during this pandemic, to cancer patients and their families, who are often part of the entire treatment process?

Lichtenfeld: Cancer patients, unfortunately, are at higher risk for complications of COVID-19 or for getting it if they get the infection in the first place.

We have been sharing that it's really important for cancer patients and their families to take this seriously, to protect themselves as much as possible, especially if they're on treatment or have recently been in treatment.

Some studies suggest that as far out as 3 years after chemotherapy, there may be some problems. There may be some disagreement about that, but the point is important.

Take care of yourself, shelter in place, follow the recommendations, be around people who use masks, wash your hands, socially distance. Families can have a huge role in making sure that their loved ones stay safe. It may be a matter of doing the grocery shopping and making sure that a parent is cared for properly. But take extra-special caution. When we say wash your hands, wash your hands. Use hand sanitizer.

All of those messages are what's most important to keep yourself safe. That's true for everyone but especially for patients with cancer.

Whyte: Dr Lichtenfeld, I want to thank you for taking time today.

Lichtenfeld: Thank you. It was a pleasure.

Whyte: And I want to thank you for watching Coronavirus in Context. I'm Dr John Whyte.

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