In the Cancer and COVID-19 CME event hosted by Penn Medicine and featuring Dr. Anthony Fauci, Dr. Lynn Schuchter, Chief, Division of Hematology Oncology at Penn Medicine discusses the evolution of cancer care delivery during COVID-19. She elaborates on the timely care of cancer patients and how to protect cancer patients from COVID-19 infection. In addition, she explains the process of reducing complications of COVID-19 infection in patients with cancer and how Penn Medicine worked to protect physicians, nurses, and other health care workers who were interacting with cancer patients.
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Twitter @PennMDForum Dr. Schuchter’s physician profile
uh, thank you, everyone for joining us tonight. I think it's been, uh, just a wealth of information. I'm gonna switch gears a bit and, uh, yeah, focus on MAWR. The delivery of cancer care during the Cove in 19 Pandemic and really sharing our experiences here at Penn Medicine on dshea ring Some of the national guidelines that have been established and we have some overarching principles that we're considering one is the timely and high quality of cancer patients that needs to continue. We want to protect our patients from Cove in 19 infection. We want to reduce their complications. And of course, you want to protect all the physicians, nurses and our health care workers. Um, and I've been thinking about the evolution of cancer care during the pandemic. This evolution is very short period of time over a 6 to 7 month period. But at the beginning of co vid, we really were focused on creating capacities and our hospitals to be able to care for the potential surge of patients with Cove in 19 infection. And we actually were downscaling on cancer care. We were forming multidisciplinary teams to see how we could modify treatment regiments, which patients could be postponed or have their treatment delayed. We were doing no cancer screening and a lot of crisis management and trying to really establish the best protocols for safety for our patients and health care workers. Now we're entering. I think more of a cove. It stable, although a little bit hesitate to use that word because this is still a very dynamic situation. But we're now in a phase where we're providing cancer care and really coexisting with Cove. It we figured out how to switch to telemedicine. We've reestablished cancer screening, but it's doctor vouching, Others mentioned not to the levels we need. Andi, we're gonna get Teoh a new future state, which I'll speak to at the end. And I just wanna mention this is similar. Tow our experience here, a pen that many of you have. I'm showing you here the occupancy rates of our hospital and this was we are a very full hospital. And in the spring, when we had our peak of the epidemic here, our capacity at our house main hospital went down to 40%. Well, what we all had to dio to create this capacity really affected how we deliver cancer care to create this capacity and the difficult decisions we had to make about those adjustments. And in oncology, um, here and just like all of your practices, we really were open and we needed to continue to provide care for oncology patients and that didn't stop during of the pandemic. And you see really relatively flat numbers here in terms of our visits. But what did change during our peak is this very rapid switch to tell health. And many of us have adopted this new way of delivering care, which has been, I think, quite effective in many situations. And now we're a this phase where a to the peak, maybe we were 60 to 70% of our patients were telehealth. And now we're back Thio about 80% of our patients in clinic in face to face visits and only 20% of patients getting their care via telehealth. I'm not going to go through all of this. But now our goal is really to optimize patient and staff safety and importantly, optimize the opportunity for cure. And we have a number of roles that we all play first. I want to emphasize the importance of educating our patients on the symptoms of Cove in 19 and their protection. And I think because of this education and reinforcing the importance of, um, social distancing and Max mask wearing, that's why we've seen a relatively low incidence of cove in 19 in cancer patients. Mean national estimates are that about 1 to 4% of patients with cancer have experienced on infection. With Cove in 19. Our data here shows a little bit less than that, less than 2%. We've done a lot to redesign our ambulatory clinics, and I think really essential for all places is that we have this designated area to effectively evaluate patients with fever and patients who may have symptoms related to Cove in 19. This is especially necessary as we enter the fall and winter, where patients are gonna come in with flu and these patients need to be in a specific area away from the rest of the ambulatory population. Frequent use of multidisciplinary tumor boards, which I think have been, um, or important than ever with broad representation of radiation, oncology, surgery, medical oncology as we've made these adjustments in how we make treatment decisions. We've seen MAWR use of tumor boards, which are now virtual, and we can include more people. And we've understood that we have to individualize our discussions about risk and benefit of treatment, um, in an individual patient with cancer, depending upon the stage, etcetera. But what we know is that it is safe to give treatment and routinely holding treatment is not recommended for our patients, and we need to continue toe deliver this in a safe way. So when a touch on sort of three big points that we face every day first, who should have covert testing in our patient population? Well, obviously, patients with symptoms We've heard much about that fever, cough and other symptoms. But this is especially hard in our oncology patients. The differential diagnosis is more difficult because there's an overlap of cove in 19 symptoms with other infections that are, patients may have complications of treatment or their disease so very difficult sometimes to make that distinction. But when we're testing patients for Cove in 19 and a symptomatic patient, this needs to be done in a designated hot zone away from patients who we don't suspect to have an infection. Then how about in patients who don't have symptoms? So there are no national recommendations about who should be tested? But I would say that there's a growing consensus that I'm sharing with you what we're doing here at Penn and similar to ASCO guidelines in N. C. C. N. So we're doing co vid 19 testing in patients who are undergoing a stem cell transplant, any type, those that are undergoing cellular therapy. Those patients that air getting admitted for chemotherapy, um, into the hospital were doing pre Admission Cove in 19 testing these air usually acute leukemia lymphoma. And we're doing testing for every patient who starts radiation therapy. There's a growing question about patients with certain types of lymphoma and regimens because of the therapies that are directed towards B cells. Maybe this really is a patient population that is more susceptible to severe complications of Covic or incidents. So there's a question, and some centers have adopted testing in these patients, and obviously testing in this situation is in a cold zone. Not where patients are symptomatic and could be could have the infection. And there were also testing prior to cancer surgery. Any invasive procedure, especially in Paris, analyzing procedure that's done generally three days prior to this procedure and done in a cold zone. Now, as I mentioned, it's still not common for patients with cancer to have a cove in 19 positive and developed coronavirus. But what do we know about their care? I mean, in general, the approach to treating the cove in 19 infection is similar to other patient populations. But just to add that these patients often becomes sick quickly. So we have the experience of someone looking well and clinic. We get a test and 24 hours later, there in the Miku so the acuity can change very rapidly. We generally hold active anti cancer treatment if someone test positive for Cove in 19. Now, there are situations that you may not be able to interrupt induction leukemia. There certainly situations in the middle of a radiation therapy where you may not choose to hold that treatment, and that's gonna be really individualized. A clinical decision making it's really essential that were much more proactive on advance care planning. We've heard the data patients with advanced cancer, older age, um, advanced stages of cancer. If they get Cove in 19, a very high mortality rates. So it's important for us to have early conversations about goals of care and what patients wishes are then in terms of resuming cancer therapy safely. Kathleen touched on this a bit, but at the beginning of the pandemic, we were using more of a test based strategy, and we needed to see to negative test before we would resume treatment. But as she mentioned, these molecular tests can remain positive for some time, though not infectious, and we certainly saw that patients had considerable delays in resuming their treatment. Eso Now it really is a time based strategy. And so the recommendations. And this is in conjunction with our own um, infectious disease. And with the 500 really growing national consensus about using time, based that you wait at least 10 days that have passed since the symptoms first appeared. At least 24 hours have passed since the last fever and that symptoms are generally improving. That's a group of patients that we would say we could begin to consider resuming therapy when we held it because of an infection. If patients were very severe or critically ill, with Cove it one could wait up to 20 days because thes patients may be sicker and that really begins to reach the limits of what we continue to see. Um, infections that can be transmitted Sometimes we would use a test based strategy in this situation to before saying, Really, it's safe for someone to return thio therapy, depending upon how ill they were. I just wanna also mention just ongoing day to day challenges that I think are facing all of you. One is the consistent implementation of the safety practices. So we've said we want our patients back. We wanna create a really safe environment. But this could be challenging. And I think people are getting weary and we need thio. Um really continue to model the very best behavior. Um, we're challenged with patients and staff, not always wearing masks appropriately. And I will say this is a attention in a clinic area of trying thio Um facilitate, you know, people wearing masks appropriately, but this is really critical to the safety of our patients. I'll just say we have a lot of signage here, and we've done been very careful about moving the furniture so that we again create a very safe environment. But people are moving the furniture together, and so we literally making signs. Please don't move furniture. I just wanna also touch on this issue of visitors for our oncology patients. It still is very restrictive, and this is still very challenging. But we think this is the safest way to go. Right now, we're allowing one visitor in the hospital for our cancer patients and in the outpatient setting, it's very limited. Many of our patients are not allowed to bring visitors back. We make exceptions such as a new patient delivering bad news. The patient is frail, difficulty understanding. But I would say that this is still really hard. There are a lot of emotional needs of our patients, and we continue to look at this policy. But as we move into the fall and winter, and as we're seeing rising um, positivity rates at the moment, we're continuing these restrictions, which I know it's really hard for the providers, for the patients and for their families and just thio begin to conclude. It's also really been an emotional toll on health care providers. And just at this year's Ehsmoh they presented the first survey of health care workers showing the tremendous burnout. Andi, I'm showing you this graph, which shows the emotional response to disaster. Onda. We were certainly in the heroic phase, and we see the cheering in New York City and then the honeymoon phase. But I know many of you shared with me the disillusionment phase as this was getting really hard, and I think we are resilient. We certainly as oncologist providers are resilient, and we have a lot more time that we're going to be a coexisting with Cove it and so all of us working together to take care of each other as we're through this period is really essential silver lining of some innovations in cancer care driven by Cove. It really the rapid adoption of telemedicine, which I think is here to say, has been fantastic. And is Ciara briefly mentioned. We've successfully shifted some impatient regimens, tow home safely. Some outpatient regimens tow home, and this has been a win win for our patients and their families, and it's been safe, and I think this will continue. And so just to conclude the first future state, I think there's important things that we really have to understand. So many speakers tonight have touched on that we've modified treatment regimens and we've delayed therapy. We really have to understand the outcomes and in our cancer patients, in terms of survival about these delays and what the impact is gonna be. We're really concerned about the delays and cancer screening and at our own, um, here at Penn Medicine, we're not back up to the levels that we previously have seen. So again important for us to encourage patients, it's safe to come in. This is really important for us to understand the impact huge hit on clinical trials in cancer research. That's really important for us. To get this up and running, we will need regulatory and payment models. Thio modified to that we can support telemedicine. Things has been a great advantage and I think will be here to stay and will be very helpful for our patients and really critical for our organizations to remain, um uh created a capacity to really deal with these dynamics. Dynamic up and downs of scaling up and scaling down a sui provide care for our patients. So I know that we can do this safely and it's really important that we do this. Thank you so much.
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