COMMENTARY

Be Skeptical of COVID-19's Proposed 'Silver Lining' for Oncology Care

Ravi B. Parikh, MD, MPP

Disclosures

August 03, 2020

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Ravi B. Parikh, MD, MPP

It was Thursday, and I was doing what I do now on Thursdays. In an effort to reduce potential COVID-19 exposure, I look through my schedule for the next week to determine which patients could be seen via telemedicine and which need to come to the office.

The decision is clear for most, until I get to the last patient on my schedule; he is the least straightforward to decide. He started a new oral therapy for advanced prostate cancer 2 weeks ago and needed labs, a toxicity check, and a medication refill. He wasn't sick, and he could be switched to a televisit. But his new medication put him at risk for problems with his blood pressure and liver function. Certainly, he could get a lab draw at home to monitor toxicity, but that posed another potential problem should something be wrong with his labs.

Ultimately, it was a judgement call. I decided that he could safely stay out of clinic and be consulted via a phone call the next Monday afternoon. Yet, as I prepared to call him, one of the nurses let me know that the patient was there for his visit despite having received my voicemail.

"I haven't seen you in a while," he said. "I figured I'd come in rather than do a phone call."

COVID-19 has forced all of oncology to rethink how we deliver healthcare. Despite the dramatic shifts in care, some have argued that there is a silver lining in this pandemic. Some of the moves we've made to shift cancer care to the home or toward more evidence-based diagnostic or therapeutic strategies could last beyond this time period. But gaps in oncology care are a product of systems, and those underlying systems haven't changed during the pandemic.

Care at Home: A Double-Edged Sword

Several well-profiled case studies have shown that COVID-19 has accelerated efforts to shift care closer to home, and pilots to increase home infusions during the pandemic have been demonstrated to be feasible. As these efforts have grown, many in the cancer care community have come to see cancer care at home as a key component of patient-centered treatment, and not as a short-term fad.

Yet while discussions about achieving this goal have increased, entrenched interests from affected stakeholders have already reared their ugly head. In early April, the Community Oncology Alliance issued a statement saying that it "fundamentally opposes home infusion of chemotherapy, cancer immunotherapy, and cancer treatment supportive drugs because of serious patient safety concerns."

At most hospitals, including my own, oncology was deemed an "essential" medical specialty, largely exempt from hospital and health system–wide requirements to shift patient care out of the clinic. In other words, while many medical specialties were forced to become entirely telemedicine-based, oncology was one of a few specialties where continued in-person care was allowed. As a result, it was relatively rare for patient volumes to drop more than 50% even during the height of the pandemic in the Northeast.

Most oncologists have seen that, despite explicit efforts from clinics and governments asking people to stay home if needed, patient volumes in areas that are past the peak of the pandemic have rapidly increased. Many oncologists are operating at pre-COVID-19 levels – and perhaps at even a greater volume to respond to a backlog of delayed treatments and procedures.

The devil you know (cancer) is sometimes scarier than the devil you don't (COVID-19).

I've seen some of the perils of trying to shift patient care to the home. Patients can be understandably frustrated by the process. Lab draws are often delayed. Relying on mail for refills is fraught with error. And, despite the recent enthusiasm for giving cancer treatments at home, most pilots of cancer care at home are limited to injections, such as leuprolide, or relatively straightforward infusions, such as infusional fluorouracil. The risks for infusion-related reactions have scared many cancer centers away from being more aggressive in chemotherapy-at-home pilots.

I anticipate that cancer care at home will increase for most oncologists, but not to the extent most think, and will be primarily driven by the preference of patients rather than by clinics or physicians. If given the choice between delaying labs or therapy to stay at home vs risking virus exposure to receive an infusion in the clinic, I suspect most patients will choose the latter. The devil you know (cancer) is sometimes scarier than the devil you don't (COVID-19).

Changing Therapies: A Recipe for Non-Evidence-Based Care?

A patient of mine with advanced bladder cancer needed systemic treatment. Normally, I would treat him with platinum-based chemotherapy, which was recently shown to be superior to checkpoint inhibitor monotherapy for patients with his type of bladder cancer. But many of us were wondering whether we should defer immunosuppressive regimens to avoid COVID-19 risk. It was a difficult decision. I asked him how he felt, and his answer left no doubt: "Give me the best treatment. I'll be careful about the virus."

Many of us have faced decisions about whether to delay certain therapies, including chemotherapy or surgery, to avoid risks for virus exposure or decompensation. Some have argued that this pandemic may discourage certain types of unnecessary cancer treatment, including extended-course radiation and certain adjuvant therapies. Although this may very well be true in some cases, I worry that COVID-19 will on the whole lead to the use of non–evidence-based treatment, including fewer courses of chemotherapy; a preference for less effective therapies, such as immunotherapy; and delayed treatment overall. These strategies have little evidence base or, worse, have been shown to lead to inferior outcomes.

Unfortunately, professional bodies have released little guidance for oncologists about how to approach such treatment decisions. When they do, they are usually general and, arguably, unhelpful. For example, a guideline released this May by the American Society of Clinical Oncology regarding administration of chemotherapy at home states, "The decision to administer chemotherapy in this setting should be made by the treating physician in consultation with the patient." I understand that these guideline bodies don't have much evidence to go on. But how is a statement like that helpful?

When oncologists are left to "fend for themselves" during a crisis, without appropriate guidance regarding treatment selection from these bodies or other experts, it's likely that the use of non–evidence-based treatment will go up.

Telemedicine: A Tale of the Haves and Have-Nots

The rise of telemedicine visits in oncology has been particularly interesting to observe. This March, one center reported that telemedicine visits represented 90% of all patient visits. Although these numbers will decrease as the pandemic subsides in certain states, it's likely that certain patients (eg, survivorship visits) will continue to receive telemedicine visits based on their own preference or that of their doctors for a while.

But, as my initial patient anecdote explains, telemedicine is deeply distrusted by or concerning to many patients, who worry that something will go missed. And, honestly, they are right to think that.

For better or worse, COVID-19 is a hypothetical risk, whereas cancer is a definite one.

But my greater fear is that a focus on telemedicine and remote monitoring will worsen preexisting disparities in cancer care. Many of my non–English-speaking or minority patients hate telemedicine visits. Some may feel that they are getting suboptimal care. Others are disturbed by poor internet connections, or the fact that they do not have webcams. Minority groups, such as African American persons, are already less likely to trust healthcare innovations like telemedicine. In these communities, pushing telemedicine appointments may subtly erode trust or accelerate disparities in unintentional ways.

So What Will Change?

If I had to predict, 1 year from now, much of the excitement that COVID-19 will spur a wave of "value-based oncology" or "patient-centered care" may be revealed to have been overblown.

To state the obvious, cancer is different from other diseases. Most of my patients desire face-to-face care, relatively frequent visits, and the best possible therapy without delay. For better or worse, COVID-19 is a hypothetical risk, whereas cancer is a definite one. Trying to force practice change onto patients with a life-threatening, polarizing disease such as cancer is unlikely to generate much success.

But will nothing change? I think, as with most things, doctors will vote with their wallets. According to the latest Medscape compensation report, practices across all specialties report a 55% decrease in revenue and a 60% decline in patient revenue. Oncologists have not been spared. Their practices have been absolutely destroyed during the pandemic. Furthermore, it has disproportionately affected private practices, who are more dependent on short-term revenue to survive.

Even though patient volumes will start to go back to normal for some practices, the threat of another COVID-19 wave or separate shock to their finances may spur some oncologists to reconsider payment models other than fee-for-service. Such "alternative payment models" may offer a more predictable revenue stream for oncologists by providing bundled and/or performance-based payments rather than fee-for-service.

For example, an oncologist participating in a fully "bundled" payment model could have earned a fixed price for a patient during the pandemic and thus would have had more flexibility to manage a patient with home infusions or telemedicine visits, which may not have been possible under the traditional model.

Currently, only 8%-25% of oncologists participate in an alternative payment model. I suspect that the appetite to do so will increase. This is a good thing. In exchange for a more predictable revenue stream, overall costs may be curtailed, and oncologists may be more willing to adopt more evidence-based, pathway-driven, or lower-cost treatment paradigms in order to "share savings."

Although we should be tempered in our hope that COVID-19 will spark a revolution in oncology care, I think there are silver linings. However, until the underlying payment and reimbursement system is changed, it will be difficult to see lasting change coming from this or similar shocks to the system.

Ravi B. Parikh, MD, MPP, is a medical oncologist and faculty member at the University of Pennsylvania and the Philadelphia VA Medical Center, an adjunct fellow at the Leonard Davis Institute of Health Economics, and senior clinical advisor at the Coalition to Transform Advanced Care (C-TAC). His research and writing focus on policy and innovation in cancer care, with specific interests in advanced illness and predictive analytics.

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