This year, the annual "Trending Now in Cancer Care" report of the Association of Community Cancer Centers (ACCC) provides a comprehensive overview of the way oncologists are coping with the challenges of the pandemic. The report, which covers the year 2020, addresses the pandemic's unprecedented strain on program resources; staff stresses and emotional isolation; increased innovation in cancer care, including telehealth; and flexibilities in clinical research to correct health inequities.
While the new report documents the acute stress of cancer program staff, it also cites resilience, adaptation, and silver linings, including new operational approaches and workflows to ensure continuity of care.
"This report is critically important and unlike any other, in that we are able to identify the impact of the pandemic on cancer programs and their staff, and tailor our resources to incorporate the lessons learned over the past year," said ACCC President Krista Nelson, MSW, LCSW, OSW-C, FAOSW. She is Program Manager of Quality and Research, Cancer Support Services & Compassion for the Providence Cancer Institute in Portland. Her theme as ACCC President is "Real-World Lessons from COVID-19: Driving Oncology Care Forward."
Instead of sending out a survey to ACCC members during the public health emergency posed by the pandemic-as has been done in past years for its annual "Trending Now" reports-the ACCC convened three focus groups in November and December 2020 to gather information from its members on staffing and operational integrity, service line delivery and revenue optimization, telehealth and supportive technology, clinical research, and health equity.
"Feedback from members reaffirmed ACCC's commitment to focus on education and resources to promote equity, diversity, and inclusion within oncology, and build a culture of resilience for cancer care staff," Nelson stated.
Trends During COVID-19
Key findings of the new report include the following trends.
COVID-19 took a heavy toll on cancer program staff. Focus discussion participants most frequently used the words "burnout," "exhaustion," "fatigue," and "stress" to describe the challenges of the pandemic. Workloads increased and provider and staff responsibilities did so as well. Many staff contracted COVID-19 or experienced financial hardships caused by furloughs and layoffs. Mandatory physical distancing contributed to social and emotional isolation for many staff and patients, and providing support for staff became a full-time occupation for many leaders and program managers.
As one focus group participant put it, "We're not having the direct interaction within the office. In terms of workload, it means that, after we see the patient, we must make other contacts to make sure things are carried out, like scheduling and scans. We want all those things done during the office visit, but that can't happen if staff aren't there."
Cancer programs were forced to adopt telehealth virtually overnight. In the spring of 2020, virtual visits accounted for abut 40 percent of patient volume, which fell to 10 percent during the summer of 2020 but accelerated to almost 50 percent during the fall of 2020. To appreciate the rapidity of the shift to telehealth, it is important to note that during live polling of attendees at the 2019 ACCC National Oncology Conference, nearly half of those polled (44%) said their cancer program did not currently use telehealth at all.
In 2020, Congress took action to increase reimbursement for telehealth for Medicare beneficiaries and to adopt telehealth regulatory flexibility. But barriers remained, including logistical and infrastructure ones. These included lack of staff to implement telehealth technology; the need to use virtual platforms like Zoom with little or no training or support; lack of equipment, such as cameras and speakers; lack of access to technology and connectivity; initial lack of codes for reimbursement; and lack of comfort with telehealth among physicians, who much preferred seeing their patients face to face.
The report also noted that "virtual visits increased expectations abut the volume of patients that clinicians can see in a day, and oncology team members had to absorb some tasks usually performed by colleagues."
One ACCC focus group participant said, "I don't have a camera in my office. I had to go and purchase one. I can use my laptop, but the laptop doesn't connect with the electronic health record. There's still a lot of issues that need to be addressed."
While some cancer programs provided patient financial navigation and supportive services by telehealth, many patients did not have access to the necessary technology or even Internet connections. Patients were difficult to reach by telephone and unfamiliar with navigator cell phone numbers, so many did not answer calls, adding to patient navigator workloads. Similarly, other supportive care staff using telehealth had to schedule follow-up calls to reach patients, sometimes multiple times.
Cancer screening volumes dropped dramatically during 2020 and have yet to catch up to pre-pandemic levels. Screening colonoscopies, PAP smears, and mammograms dropped, either because screening sites closed, primary care providers canceled screenings, or patients canceled appointments for screenings. Many patients avoided the emergency room, where incidental findings of cancer can be detected. One cancer program reported a 50 percent reduction in new breast cancer diagnoses in the second quarter of 2020 and a 20 percent reduction in new breast cancers in 2020 overall. A similar pattern is anticipated for other cancers detected by screening.
As previously reported by Oncology Times, many oncologists now believe that the dramatic reduction in cancer screenings and regular preventive appointments caused by the pandemic will lead to more cancers being diagnosed at more advanced stages, when they are less treatable. ACCC focus group members stated that tumor registries will likely record the diagnosis of more advanced cancers in 2021 and even in the years beyond.
The pandemic's hit on the U.S. health care system took a financial toll. Some health systems stopped outpatient or scheduled appointments and suspended whole patient service lines. Reductions in overall patient volume and elective procedures had an adverse effect on revenue.
Because cancer patients in active treatment kept their clinic visits, oncology programs actually shored up health system revenue in many cases. But for cancer programs, the marked drop in cancer screenings led to lower new patient visits, which led to furloughing and laying off staff; flexing staff to patient volume; freezing and/or eliminating merit increases; implementing voluntary and involuntary salary cuts; and putting matching IRA contributions on hold.
One ACCC focus group participant said, "The ambulatory clinics closed down in March and April. Those nurses moved to the inpatient units, and the staffing just kind of moved around." The new report states, "Staff workloads increased, roles were reshaped, and many cancer program staff absorbed new responsibilities as colleagues were furloughed or redeployed."
Some Good News
Among the silver linings caused by adaptation to the pandemic were these, according to the new report on trends in cancer care.
The pandemic sparked a national conversation on existing health inequities. Cancer programs responded to concerns about disparities due to socioeconomic, racial/ethnic, age, gender, and geography factors by scheduling flexible clinic and treatment hours for working patients; help with transportation for appointments; addressing food insecurity and child care needs; and partnering with community organizations to reach at-risk patients.
Financial navigators became even more important as patients suffered economic hardships caused by the pandemic. In response to the need for financial navigators to work from home and reach patients by telephone, the ACCC developed a COVID-19 Financial Advocacy Resource Hub and shared tips for financial navigators via a town hall.
To combat the loss of in-person social connection and the disruption of professional and personal life, cancer programs repurposed conference rooms and other areas as designated staff spaces; started innovative methods of staff recognition and perks (such as hosting milkshake and ice cream bars); developed robust "buddy" systems; sent daily supporting messaging; shared positive stories and accomplishments; and reinforced a culture that encouraged staff to speak up, especially when issues and challenges arose.
Flexibilities were established in clinical research which have long-term potential to reshape the design and conduct of clinical trials, increasing access and potentially addressing health disparities. These included decentralizing care based on guidelines from the FDA; implementing remote consent and trial eligibility screening; clarifying which tests are essential; amending studies to eliminate lab test times or lengthen testing intervals; using virtual visits for clinical assessment and patient-reported symptoms; leveraging biometric devices to support patient evaluation; shipping oral drugs directly to patients; and deploying pharmacists to counsel and monitor medication adherence by telephone.
In October 2020, the ACCC released recommendations on how health professionals could creatively increase cancer screenings. These include use of mobile medical clinics to deliver screenings; development and dissemination of safety protocols directly to patients-and through social media-to show how hospitals and clinics are keeping patients safe; outreach and education to local media and community organizations about new measures to ensure safe screenings and the importance of not putting off regular appointments, and to ask for their help to disseminate this information and encourage patients to resume screenings; and proactive outreach to patients to remind them of their need for screenings, and to engage in personal conversations to allay fears, rather than waiting for patients to schedule or reschedule their appointments.
In issuing these recommendations, the ACCC warned: "After so many years of steady decrease in both mortality and late-stage diagnosis rates, the health care community understood the catastrophic impact that COVID-19 might have on screenings and diagnoses. The rise in advanced metastatic rates and change in death rates we see [in new data] is a dire warning to all sectors of health care to do whatever it takes to encourage screenings and reassure patients."
Peggy Eastman is a contributing writer.