Cancer Patients Often Excluded in US State Crisis-Standards-of-Care Guidelines

By Marilynn Larkin

December 09, 2020

NEW YORK (Reuters Health) - U.S. state crisis-standards-of-care (CSC) guidelines, which allocate scarce health resources among patients, often deprioritize or exclude cancer patients, researchers say.

"Our cancer-focused analysis of state...guidelines found that four months after the first U.S. case of COVID-19, 19 states did not have a publicly accessible guideline - i.e., not available through public search and not confirmed on state websites - and the majority that did deprioritized and/or excluded at least some patients with cancer during critical care resource allocation," Dr. Andrew Hantel of the Dana-Farber Cancer Institute in Boston told Reuters Health by email.

As reported In JAMA Oncology, Dr. Hantel and colleagues analyzed state-endorsed CSC guidelines published before May 20, 2020 that included healthcare resource allocation recommendations. Guidelines from 31 states were included, of which 17 had been published or updated since the first U.S. case of COVID-19.

States in which available hospital bed capacity was predicted to exceed 100% at six months or with a National Cancer Institute-designated Comprehensive Cancer Center were more likely to have publicly available guidelines.

The most frequent primary methods of prioritization were the Sequential Organ Failure Assessment score (27 states; 87%) and deprioritizing persons with worse long-term prognoses (22 states; 71%).

Allocation methods for 17 states (55%) included cancer-related deprioritizations, and for eight states (26%), cancer-related categorical exclusions.

An in-state comprehensive cancer center (CCC) was associated with a lower likelihood of cancer-related categorical exclusions (multivariable odds ratio, 0.06).

Guidelines with disability rights statements were associated with provisions to allocate blood products (multivariable OR, 7.44). The presence of both an in-state CCC and an oncologist and/or palliative care specialist on the state CSC task force were associated with the inclusion of palliative care provisions.

The authors state, "These data suggest that equitable CSC considerations for patients with cancer would likely benefit from the input of state-level oncology stakeholders such as CCCs."

Dr. Hantel said, "In addition to our cancer-focused findings, others have found that different demographic groups, such as older adults, may also be at risk for deprioritization/exclusion during CSC resource allocation. While we do not know if or how cancer- and age-related deprioritizations or exclusions overlap, guidelines with both may inordinately affect older adults with cancer."

Dr. Beth Virnig of the University of Minnesota School of Public Health in Minneapolis, coauthor of an accompanying editorial, commented in an email to Reuters Health that reducing disparities "is about transparency of decision-making -- i.e., having a clear process to determine what changes to care must be made because of COVID and to make sure that this is consistent across providers and settings."

"Clinicians who participate in the guidelines process can help argue for more specific guidance and perhaps suggest that the guidance should vary by setting of care," she said. "So, while ventilators and hospital beds are in short supply, other types of care may have capacity."

"Clinicians should be aware that there are two sorts of themes around COVID: saving supply of scarce resources for those patients with the greatest need or greatest likelihood of benefit and protecting patients from risks of healthcare-related infection," she added. "Taking time to consider the 'why' is important. For example, some people might avoid going to the doctor out of worry that they will become infected with COVID. Other patients might have scheduled appointments postponed because the hospital is trying to conserve PPE."

"For cancer," she said, "there can very definitely be a price associated with delayed care -- especially for people who have symptoms."

SOURCE: and JAMA Oncology, online December 3, 2020.