Cancer centers have changed the way they deliver care to face challenges brought about by the COVID-19 pandemic, but will these changes stand the test of time?
Centers have reported successes with expanding and streamlining telemedicine and coordinating with affiliated sites.1 Making more cancer treatments available for at-home administration has been another change prompted by the pandemic.2
However, it isn’t clear if these emergency changes the pandemic necessitated will become ingrained in cancer care. The use of telemedicine, for example, has decreased from earlier in the pandemic,3 even as the United States recently reported record-breaking numbers of COVID-19 cases.4
Coordinating With Affiliated Sites
A recent report by a National Comprehensive Cancer Network (NCCN) committee noted that, during the first year of the pandemic, urban cancer centers struggled to meet the demands of oncology patients when hospital space had to be dedicated to COVID-19 patients and staff were redeployed to pandemic-related initiatives.1
Shifting some cancer patients to affiliated sites in surrounding communities was “a key coping strategy,” according to the report.
Before the pandemic began, the Massachusetts General Hospital Cancer Center (MGHCC) in Boston was already in the process of building out specialized care resources at its community partner sites located in suburban areas outside of the city. The pandemic expedited that plan, shifting “new and established patients, infusion volume, and physicians to the network sites quickly and systematically during the height of the pandemic,” the authors wrote in the report.
To make this transition easier, MGHCC standardized workflows, visits types, and provider schedules across the different sites. In this way, MGHCC was able to decrease new patient volume at the main center by 6% and increase new patient volume at network sites by as much as 25%.
At Penn Medicine’s Abramson Cancer Center, there was a similar shift in patient volume from the main center in downtown Philadelphia to suburban sites, but this change was driven by patients.
Patients may have been reluctant to come into the main cancer center because urban centers had been crowded prior to the pandemic, according to Lawrence Shulman, MD, deputy director for clinical services at Abramson Cancer Center. The suburban sites were smaller and appeared less crowded, so they may have felt safer to patients.
Regardless of the reasoning, as a result of this shift, infusion volume at the main center decreased by 20%, and some suburban sites saw an increase of 25% in 2020.
Use of Telemedicine
Another change highlighted in the NCCN report was learning to better navigate telemedicine.1 According to the report, telemedicine can be improved by using a single platform integrated into a center’s electronic health record and developing new workflows to integrate telemedicine. Providing patients with technical support and collecting and responding to their feedback can help them adapt to telemedicine as well.
As far as how best to use telemedicine in oncology, an NCCN survey of more than 1000 oncology providers suggested that visits to review benign data, follow-up or surveillance visits, and visits explaining important malignancy-related data are well suited to telemedicine.5
“Where telemedicine adds a ton of value is when you are essentially going over follow-up data in a situation where you know the patient well and you understand what’s going on,” said Timothy Kubal, MD, of Moffitt Cancer Center in Tampa, Florida, who coauthored the NCCN report. “[Telemedicine is] great when what you need is a conversation, and there’s a lot of areas in medicine where that’s all you need.”
At some cancer centers, telemedicine was already on the horizon before the pandemic began, but the pandemic expedited its movement to the forefront of care.
The Sidney Kimmel Cancer Center at Thomas Jefferson University in Philadelphia conducted virtual appointments with 5% to 10% of its patients before the pandemic, according to Nathan Handley, MD, an oncologist at the center. At the height of the pandemic, the percentage of virtual appointments was as high as 70%, but it has settled at around 30% to 40% more recently, Dr Handley noted.
Dr Kubal said he would have expected telemedicine use to rise again as COVID-19 cases have surged due to the omicron variant,4 but that hasn’t happened.
“One of the things I think we were surprised by was the number of patients who wanted to come back for in-person visits,” he said. In the past 6 months, he added, patients have started to come in person for visits that could be conducted virtually.
Another factor that may affect the longevity of the increase in telemedicine is reimbursement. The Centers for Medicare & Medicaid Services expanded reimbursement for telemedicine services in response to the pandemic, and the 2022 Medicare Physician Fee Schedule Proposed Rule includes the temporary extension of many telemedicine services, but this only extends through the end of 2023.1
“One concern we have is that a lot of these … telemedicine waivers are going to get rolled back, probably,” Dr Handley said. “I think we will lose a lot of momentum when that happens. It’s been very liberating to be able to just do telemedicine with patients, regardless of where they are. I’ve had patients who have had to travel, and I’ve been able to still do telemedicine with them.”