By Randolph Fillmore
With this year’s observance of “Breast Cancer Awareness Month,” breast cancer awareness and concern about optimal treatment has come with an unwanted “October surprise.” Early in the pandemic it became clear that cancer care needed to be modified to reduce the risk of COVID-19 infection for both patients and their health care teams. But COVID-19 is still around.
How is the nasty virus affecting, or not affecting, breast cancer diagnosis and treatment?
Surprisingly (or unsurprisingly) experts do not agree. With telemedicine and video conferencing playing a strong role, some say breast cancer treatment is, for the most part, unaffected by COVID-19. Others say that treatment has been “quite affected” by COVID-19 with treatment and patient follow-up dependent on “virtual medicine” via “telemedicine” but may not substitute for the doctor/patient up close and personal experience.
Questions have also been raised regarding whether breast cancer patients have been happy with the Zoom results or really miss that “personal touch.” For breast cancer patients, this is an ongoing important issue going forward as the pandemic, at least in the US, appears not to be slowing down.
Zoom or doom and gloom?
In an American Society of Clinical Oncology (ASCO) online commentary, Carolyn B. Hendricks, MD, self- described as a “breast-dedicated medical oncologist” in community practice in Bethesda, Maryland, wrote a commentary titled “The Doctor Will Zoom With You Now: Telemedicine and Breast Cancer Care.”
“The most significant change has occurred with the rapid transition to telemedicine,” wrote Dr. Hendricks. “Telemedicine is loosely defined as caring for patients remotely when the doctor and patient are not physically present with each other. Telemedicine has its history in rural medicine. Telehealth visits were originally envisioned for patients living in rural areas. But initially, the patients were in health care facilities for these visits, not in their own homes. Prior to the COVID-19 pandemic, many cancer centers and oncology researchers were studying ways to deliver cancer care via telemedicine in pilot projects. The COVID-19 pandemic sped up the process dramatically.”
Dr. Hendricks said her group practice adopted telemedicine using a licensed Zoom platform in March of 2020.
“My proportion of televisits grew rapidly to approximately 30 percent,” she wrote. “The proportion has waned somewhat, but it remains about 20%. This option is made available to all my patients, including new patients. Fortunately, my practice has had a very low incidence of COVID-19–positive tests among my patients, their families, and my staff. The option of televisits has helped to reduce this risk, particularly in my highest-risk patients whose immune systems are affected by their cancer treatments, as well as for my patients who have vulnerable family members in their households. It has also helped to overcome the severe visitor restrictions that COVID-19 has imposed on our in-person visits.”
According to Dr. Hendricks, Zoom visits typically require more advance preparation by doctors, the doctor’s staff, and the patient, but Zooming seems to work pretty well.
“My patients can tell that I am fully engaged with them during the time that we share. Because the visits are timed and staggered, there are very few interruptions on either end,” she adds. “I feel very comfortable meeting new patients and outlining a treatment plan via televisit.”
Do patients miss the personal touch?
Also offered during an ASCO virtual meeting was an analysis of telemedicine visits by health care providers at the Tel Aviv Medical Center and Sackler School of Medicine, in Tel Aviv, Israel.
“Almost all ambulatory activity in the oncology division in Tel Aviv Medical Center was converted to telemedicine services,” said the authors, who conducted a telephone interview questionnaire assessing patient satisfaction. Inclusion criteria included solid tumor patients over 18 years of age who utilized the telemedicine platform at Tel Aviv Sourasky Medical Center between March 2020 and May 2020. Survey aimed at evaluating patients’ perspectives and preferences regarding telemedicine and assess whether virtual communication affected the patient-doctor relationship.
The authors reported that 100 patients participated in the survey. The majority of patients independently downloaded the telemedicine application and did not encounter technical constraints and almost half had family members and friends attending telemedicine visits. Of those surveyed, 18 percent were breast cancer patients. Visit intent included post-treatment follow up (40%), active treatment follow (53%), and first visit intake (7%). The majority of patients felt their emotional needs were met (88%) and said that their treatment was not harmed due to absence of a physical visit (84%). Ninety-nine percent felt their privacy was maintained and 95 % of patients affirmed that the virtual visit relieved their worries regarding treatment interruption; 75% of patients affirmed their interest to continue telemedicine regardless of COVID-19 pandemic.
In a paper published in the April 20 issue of the journal Breast Cancer Research and Treatment, titled “Recommendations for prioritization, treatment, and triage of breast cancer patients during the COVID-19 pandemic” the authors said that the COVID-19 pandemic presented clinicians with “a unique set of challenges in managing breast cancer patients.”
They noted that as hospital resources and staff became more limited during the COVID-19 pandemic, it became critically important to define which patients required more urgent care and which patients could wait for treatment until the pandemic ended.
The authors used the expert opinions of representatives from multiple cancer care organizations to triage breast cancer patients into priority levels (A, B, C) for urgency of care across all specialties and provided treatment recommendations for each of these patient scenarios. Priority A patients had conditions that are immediately life-threatening or symptomatic requiring urgent treatment. Priority B patients had conditions that did not require immediate treatment but should start treatment “before the pandemic is over.” Priority C patients had conditions that could be safely deferred until the pandemic is over.
Implementation of these recommendations for patient triage was based on the highest-level evidence available “adapted to current availability of hospital resources and severity of the COVID-19 pandemic in each region of the country,” said the authors.
Additionally, the risk of disease progression and worse outcomes for patients had to be weighed against the risk of patient and staff exposure to COVID-19.
A study looking at COVID-19’s impact on breast cancer care delivery early in the pandemic at the Columbia University Irving Medical Center in New York City was also found on the ASCO virtual meeting site.
“We aimed to characterize breast cancer patients without COVID-19 whose care was impacted by the COVID-19 pandemic at an academic center in New York City,” said the authors who performed a retrospective cohort study of breast cancer patients treated at a medical oncology practice between February 1, 2020 and April 4, 2020. Patients were included if they were scheduled to receive intravenous or injectable therapy or were scheduled as a new patient. Patients were excluded if they tested positive for COVID-19 or transferred care during the study period. Delays were defined as postponements of scheduled care and changes were defined as care alterations without postponements. Impact on care was defined as any change or delay in any oncologic care for which a patient was scheduled.
The study found that nearly half of the breast cancer patients experienced a change or delay in workup or treatment and, once more, “significant racial and socioeconomic disparities” impacted care.
Conclusion: Hopes for next year
October 2020 has found that, by-and-large, the medical community adapted to giving the best care possible to breast cancer patients virtually, but that conclusion may be premature as the several studies available may not be representative of a bigger picture over the length of the COVID-19 emergency. Only a retrospective look once the pandemic is over will tell the true story. Breast cancer patients and their families can only hope that a return to normal is not more than another October “Breast Cancer Awareness Month” away.