by Paige Hauke
figures by Paige Hauke and Catherine Ding
As the pandemic rages on and strict social distancing guidelines remain in place for much of the United States, COVID-19, for good reason, takes up most of the medical limelight. But as someone who works at Dana-Farber Cancer Institute and walks past our clinical buildings each day, I find myself wondering what this means for other medical conditions: how has this shift in attention affected the daily operations of patients, nurses, and physicians who still have to face different yet equally severe illnesses during this time? In an attempt to answer this question, I reached out to Dr. Ann LaCasce, a prominent Dana-Farber oncologist, who graciously agreed to share her window into how COVID-19 has transformed the world of cancer.
The start of it all
In the middle of March, as COVID-19 swept through the country and non-essential business ground to a halt, work at Dana-Farber couldn’t stop. While researchers and other non-clinical staff were instructed to work solely from home for the next two and a half months, Dr. LaCasce and her many other clinical coworkers were deemed essential. In our interview, Dr. LaCasce discussed the encouraging ways in which Dana-Farber quickly adapted to a new reality.
During the early phase, Dana-Farber called on Dr. LaCasce to cover a weekend of inpatient services for hospitalized COVID-19 cancer patients. While this, to me at least, felt like a daunting task, Dr. LaCasce remained positive about steps taken to make her feel safe in her temporary position:
It was very well-managed…They had people whose job it was to watch you put on your PPE and help you and tell you exactly what to do. I think they didn’t trust that we were going to do it correctly, which was a good assumption, because it’s a lot of steps. You know, you’re focusing, people are stressed, and it’s a very foreign environment.
Despite being a part of this crucial process, Dr. LaCasce made it clear that “the total heroes” for her during that time were Dana-Farber’s nurses, who kept treating cancer patients with little to no hesitation:
From the very beginning, they [nurses] were in very close contact with patients throughout because people needed to continue to get their infusions. And there were a lot of people who had symptoms, we didn’t know whether they had COVID or not…And they just, it was amazing, you know, without hesitation, they’re like, yep, this is what we’re doing…They really had a much harder job in some ways than the physician.
As these nurses continued to work tirelessly alongside patients, Dr. LaCasce shifted back to her more traditional physician’s role. Through the next months, she settled back into consulting with patients to find the best treatment plans and medications to help with their unique cancer experiences. But with drastically increasing COVID-19 numbers, she and the rest of Dana-Farber had to get creative, finding new ways to communicate with patients too scared to leave their homes.
Turning to telehealth
Unfortunately, as the number of COVID-19 patients grew in hospitals, the number of outpatients visiting Dana-Farber each day decreased significantly. While the institute itself continued to encourage patients to come in for necessary appointments, fear of contracting a potentially deadly virus made staying safely at home feel like a greater priority than the upkeep of medical screenings and follow up visits. The result? A drastic shift toward telehealth, or virtual consults with patients. This shift, similar to adjusting to the virus itself, was strange, but relatively successful.
Prior to that time, we’d done no virtual medicine at all, not telephone, not video. So they quickly rolled out telephone and then Zoom and then they integrated Zoom into EPIC, which is our medical record…I think the legislators made a lot of laws very quickly to support that and make it feasible from an insurance and medical legal perspective, which was great.
Dana-Farber prides itself on treating each patient as a unique individual, and Dr. LaCasce found that in some ways, telehealth helped provide an important window into the lives of her patients.
One patient I remember doing a tele-visit with and we had to change tack in terms of treatment and I’m talking with him and his wife and they’re in their kitchen and their kids are in the background walking by. And even though it was a difficult conversation, it was really nice…I like to have a vision of where they are in my head. It’s a very reassuring thing. And I think that with the video calls it’s really nice because sometimes there are family members you haven’t ever met or you see the pets or just where they live, you see the backyard. It’s just, it’s kind of cool.
Telehealth seemed to rise rapidly in popularity through March, April, and May with a large peak in June, at which point virtual appointments slowly declined as patients grew more and more comfortable with the idea of returning to Dana-Farber once more. By September, the in-person numbers rose to very near where they were prior to the pandemic. Unfortunately, despite these impressive efforts to provide virtual care during a time of crisis, some of the longer lasting, negative health effects of fewer in-person screenings and treatments are only now becoming clear.
The cost of COVID on cancer
In preparing for my conversation with Dr. LaCasce, I stumbled across an article in TIME detailing the low number of cancer screenings performed during the pandemic. For cancer types such as breast and colon cancer, screening appointments dropped by more than 80%. Because tumors are made up of rapidly growing, malignant cells, screening reductions of this magnitude are alarming. Malignancies that start out small, and can be caught through early screening, can become significantly harder to treat when given time to grow (Figure 1).
Asking Dr. LaCasce about her experiences with this phenomenon, she admitted that the new influx of patients back to the clinic has included many new or progressed cases that were made harder to deal with in their time away.
I saw two cases of people…being diagnosed with just unbelievable burden of disease, because they had been afraid to be seen either by their primary care physician or to go to the hospital. And I think there’s going to be a big impact of that for people who weren’t getting screening, but more so the people who had really advanced cancer and had not been seen for three or four months…I don’t think it probably makes a difference between a curable and incurable cancer, but, you know, I think it may make a difference between being able to offer some therapy or not.
She recalled one case that was a particularly troubling example of this:
I saw one patient who was just too sick to even think about treatment and didn’t want any anyway. Was very clear about it, and the family and I, we’re all on board. But it was just a really disconcerting situation because, had this person been seen a couple of months earlier, he might have had time to go on to have some good time with family, even if he had decided not to get any treatment. So those cases are haunting.
The road ahead
In welcoming back so many of its patients, Dana-Farber is doing its best to combat this temporary dip in in-person appointments. In October, the institute and partnering hospitals took to the news to publicly emphasize the importance of rescheduling screenings. Their biggest solution, however, continues to be maintaining as sterile an environment as possible so that patients feel less fearful of coming to the clinic. Currently, Dana-Farber have plans in place to consistently screen patients and staff for COVID-19 symptoms. It gives out clean, disposable masks each day and has drastically limited the number of visitors allowed to accompany patients to appointments, among many other safety precautions.
They’ve done an amazing job because a lot of patients coming in, they’re coming into Yawkey [clinical building] for blood draws, and then they come upstairs, and they screen everybody. It’s really been an amazing process to watch how the infection control people and the administrators try to balance all the various things that are in constant evolution.
The social distancing guidelines continue to create a somewhat isolating environment for patients and staff alike, but while Dana-Farber hopes to work back to a sense of normalcy, for now these precautions are necessary to combat both the pandemic and other threats to patient safety.
In the meantime, we should all be doing our own small part to restore that sense of normalcy. In order for cancer clinics to recover, we must work together on a larger scale to stay safe and keep others safe as well. Although by now we’ve all heard the guidelines so many times, I couldn’t help but ask for a physician’s opinion on stopping the spread of corona. Dr. LaCasce’s answer was familiar and clear:
A mask. Mask number one, two, and three. Yes handwashing too and social distancing, but the mask is critical…I think we’ve seen it over and over again play out locally and nationally; that’s the key. And they initially said it didn’t protect you, it protected others, but I think it goes both ways. It can protect you too.
Paige Hauke received undergraduate degrees in Chemistry and English from Wellesley College. She currently works as a research technician at Dana-Farber Cancer Institute.
Catherine (Xiaoxiao) Ding is a third-year Applied Math Ph.D. student in the School of Engineering and Applied Sciences at Harvard University, where she is studying programmable materials.