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Nitesh Paryani, MD, had received a referral for a patient with metastatic brain cancer who needed radiation immediately. But his hospital was full of COVID-19 patients, most of whom were unvaccinated. "We had no beds available," Paryani, the medical director of Tampa Oncology and Proton, wrote in an op-ed in The Washington Post. "Our emergency department had a 12-hour wait that day."
Paryani did something he never thought possible: He had to turn the patient away.
Fortunately, he was able to find the patient a bed at a hospital just a few miles away. But the experience left him concerned about the burden COVID-19 and unvaccinated individuals, in particular, continue to place on patients who require time-sensitive care.
Throughout the pandemic, oncologists have experienced a seeming constant barrage of challenges. Lockdowns that swept the country in the early days of COVID-19 led to delays in cancer screenings and treatment. Experts predicted more than 10,000 excess cancer deaths would result.
Last spring, the reverberations from delayed cancer diagnoses and treatment started to come into view. Oncologists reported seeing many more patients than usual presenting with advanced disease.
More recently, as the Delta variant overwhelmed US hospitals in areas with lower COVID-19 vaccination rates, oncologists and patients may be facing yet another hurdle: A scarcity of hospital beds to provide infusions and radiation, handle operative and postoperative care, or manage urgent symptoms.
But how widespread is the situation Paryani described? And is it leading to delays in urgent cancer care?
Medscape Medical News spoke to oncologists across the US to get a broader perspective. They described everything from minimal to frequent issues accessing hospital care.
"My impression is this is a hyperlocal and variable problem," said Timothy Kubal, MD, MBA, a medical oncologist/hematologist at the Moffitt Institute in Tampa.
Debra Patt, MD, PhD, MBA, executive vice president of Texas Oncology in Austin, echoed this observation.
"In general, I think oncologists are having a mix of experiences and it's very regional," said Patt. "But there are real tragedies where demand for medical care exceeds supply, such as in Alaska and Idaho, which recently went into crisis standards of care."
However, access did not always align with a region's Delta hospitalization rates and bed availability. Other factors — such as staffing issues, hospital discharge policies, and a greater push to provide oncology care in the outpatient setting — came into play as well.
The "Mix of Experiences"
Not surprisingly, local vaccination rates tend to predict how cancer care has been affected. Hospitals in areas with higher vaccination rates avoided a flood of COVID-19 patients and any subsequent disruptions in oncology care, while those in areas with lower vaccination rates were more likely to face challenges.
In Philadelphia, where 71% of adults are fully vaccinated, Adam Binder, MD, said he and his colleagues have not had to turn any patients with cancer away.
"I am happy to say that we have been lucky and our hospitals never were so overwhelmed with COVID-19 patients [during the Delta surge] that we could not provide oncology care to our patients," said Binder, a medical oncologist at the Sidney Kimmel Cancer Center at Jefferson Health.
For Barbara McAneny, MD, chief executive officer of New Mexico Oncology Hematology Consultants in Albuquerque, limited access to hospital beds in areas overwhelmed by the Delta variant has been "more than anecdotal."
"We certainly see this problem in New Mexico, and my colleagues in Texas and Florida, in particular, are struggling to find beds for their patients," said McAneny, also past president of the American Medical Association. "Thanks to good COVID-19 vaccination rates, we're not broken in New Mexico yet. We're still able to access beds for our cancer patients."
But McAneny said it hasn't been easy. When she needs a bed for a patient requiring an infusion or to treat complications from lymphoma or leukemia, she puts their name on a list and receives a call when a bed becomes available.
"Getting those beds is like pulling teeth," she said "Often, the hospital tells me to send these patients to the ER, which is the last thing we want to do because patients will be sitting around for 8 to 10 hours before they are seen."
Kashyap Patel, MD, chief executive officer of Carolina Blood and Cancer Care in Rock Hill, South Carolina, described a similar situation.
"We had resumed a sense of near normalcy during the early part of this year, but with the Delta surge, we are pretty much back to square one — long waiting times for hospital beds, hospitals on diversion, delays in planned procedures, including radiological tests, and so on," said Patel, also president of the Community Oncology Alliance.
Viral Rabara, MD, a partner at Carolina Blood and Cancer Care, described having to route some patients through the ER, instead of admitting them directly to the hospital because of a bed shortage.
"We have had several patients who had to wait 24 to 36 hours in the ER for a hospital bed to open, which led to a delay in their care," Rabara told Medscape Medical News.
Not Just a Bed Issue
Rabara highlighted another, perhaps more pressing roadblock for his patients needing hospital care: A provider shortage.
"We have seen delays in urgent chemotherapy infusions in the hospital due to a lack of chemo-trained nurses and an overall nursing shortage," Rabara said.
According to Patt, this "staffing shortage is overwhelmingly more prevalent than the bed issue."
Before the pandemic, experts had predicted 130,000 fewer nurses practicing in the US by 2025, given anticipated rates of retirement. However, the stresses of the pandemic combined with vaccine mandates for healthcare workers pushed thousands more to retire early or leave the healthcare workforce altogether.
The American Nurses Association sent a letter to the federal government in September, which provided a glimpse of the staffing situation in several states — Mississippi dealing with 2000 fewer nurses since the beginning of the year, Tennessee hospitals calling in the National Guard to help with provider shortages, and Louisiana facing more than 6000 unfilled nursing positions before the Delta surge.
"We're losing a lot of staff at my hospital, especially nurses, and my colleagues across the country are facing major staffing shortages," said Rita Nanda, MD, director of the Breast Oncology Program and associate professor of medicine at University of Chicago Medicine in Illinois. "These downstream effects of COVID are affecting immediate patient care and stalling clinical trials across the country."
With ongoing political turmoil over vaccines, an expiration on eviction moratoria approaching, and violence against healthcare workers on the rise, the level of anger and burnout among patients and staff is reaching a breaking point.
"The mindset has changed from us all pulling together to take care of patients with cancer to 'how much longer can I do this?' For doctors and nurses, even if they take vacation, they can never really get away from the stress," McAneny said.
Not Always Clear-Cut
Although the hospital access challenges oncologists encountered appeared more prevalent in areas with lower COVID-19 vaccinated rates, experiences varied.
Just over 10 miles northeast of Paryani's practice in Tampa, Kubal of the Moffitt Cancer Center said the Delta surge did not significantly impact emergency care for his patients.
"Unlike the first COVID wave in 2020, we have not backed down on any cancer care during the Delta wave, even though our COVID hospitalization numbers were double during the peak this summer," Kubal said. "At beginning of COVID, our no-show and cancellation rates were 50% or higher. We'd have clinics with no patients. Now, our no-show rate is 3%."
During the Delta peak, Kubal said the no-show numbers climbed as high as 10% to 15%, but those largely encompassed patients on long-term follow-up, not those needing immediate care.
He did recall one close call: A patient with breast cancer in an affiliated hospital whose mastectomy was canceled following neoadjuvant therapy. However, the surgeon got emergency credentials at a different hospital, and the surgery ultimately happened on time.
According to Nanda, the virus can also still impact cancer care in areas that avoided a Delta surge.
"Given the large proportion of vaccinated patients in the Chicago area, our hospital beds are not full of COVID patients, but we are facing another, more subtle problem," Nanda said. "We have patients sitting in the hospital who can't get place in a skilled nursing facility or rehab facility because of a 14-day quarantine period. Because we can't discharge these patients in a timely fashion, we are facing a shortage of beds in our hospital, and a backlog of patients sitting in the ER for days getting suboptimal care while they wait for a bed."
Care Outside the Hospital
One thing the pandemic is teaching us, Patel said, is how to help more patients in the outpatient setting.
"If I suspect a patient may have an infection, I'll bring them into the office as soon as possible to intervene early and prevent a potential hospital stay."
Like Patel, McAneny has relied on efforts to intervene early in order to prevent hospitalizations. These efforts, which involve frequent check-ins by phone with patients, were established well before the pandemic and became essential during it.
"When a patient starts to get a fever, I want to know when he is at 100, not 101," McAneny said. "You can prevent a lot of hospitalizations by aggressively managing patients' care."
Monitoring symptoms requires a lot of uncompensated work, McAneny said, but "this effort can prevent complications from escalating and has kept my patients' hospitalization rates low before and during the pandemic. Plus, patients feel better and get to be home more."
Kubal noted that some patients who may have gone to the hospital to manage their symptoms before the pandemic are now coming to see him in the clinic, and especially during the COVID peak over the summer, he tried to treat these patients in the outpatient setting whenever possible.
Patt described the importance of using the oncology team — the surgeon, oncologist, radiation oncologist — to figure out ways to safely provide hospital care or safely postpone it.
"For patients with new breast cancers, in normal circumstances we'd do surgery first, but if we are unable to accommodate that because of COVID numbers, we may manage their cancer with a drug they'd typically get postsurgery to make sure they can wait safely," said Patt. "In the US, we look at many of our resources as limitless, but now that we're operating with constrained resources and have to think creatively to provide necessary care in these more challenging conditions."
McAneny cautioned that the country's overreliance on hospitals to provide services that used to and should be done in a doctor's office or ambulatory surgical center — cancer screenings, biopsies, and chemo infusion ports — has helped create the current access bottleneck some oncologists are facing.
"We've stuffed so much care that should be happening in physicians' offices into the hospital, and we're paying the price for it now," McAneny said. "We need to decouple the acute-care system and the chronic-care system so that for the next pandemic we don't shut down our entire healthcare delivery and can allow chronic diseases to remain under control."
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Medscape Medical News © 2021
Cite this: Victoria Stern. How Delta Delayed Cancer Treatment: 'Hyperlocal' and Multifaceted - Medscape - Oct 22, 2021.