The National Comprehensive Cancer Network (NCCN) held a virtual policy summit to examine the effects of the COVID-19 pandemic on cancer care. At the summit, which was billed as "Defining the New Normal-2021 and the State of Cancer Care in America Following 2020," speakers shared data and insights on the harms of the pandemic, but also on its silver linings. These include the way quick pivots and needed adaptations in delivering cancer care have led to improvements in that care.
Global oncology trends show that oncologists' caseloads dropped during the pandemic and are still 26-51 percent below those of pre-pandemic levels, said keynote speaker Murray Aitken, MBA, Executive Director of the IQVIA Institute for Human Data Science. He noted that, while the United States had the lowest level of caseload reduction at 26 percent, through the end of 2020 U.S. screenings for common cancers (i.e., breast, cervical, colorectal, and lung) dropped.
There were an estimated 22 million fewer (missed or cancelled) screening tests for these four cancer types in 2020. "We still see screenings below pre-pandemic levels in 2021," Aitken said. "We need to watch and see how that plays out." He noted concern that people may have lost the habit of having routine, recommended cancer screenings during the disruptions of 2020, which could lead to serious backsliding if they fail to resume pre-pandemic screening rates.
While cancer screenings dropped, "relative to other specialists, oncologists saw the least impact on diagnostic visits during the lockdown period," he said. Nonetheless, more new patients presenting to community oncologists had metastatic disease in several cancers during 2020, including breast, cervical, colorectal, and non-small cell lung cancer (NSCLC), Aitken noted.
In addition to drops in oncology caseloads and screenings, "annual growth in the use of oncology medicines fell precipitously in 2020," said Aitken. Of these, growth in the use of oral oncology medicines and subcutaneous treatments has been higher than that of IV/infused treatments since the beginning of the pandemic. He noted that, while the use of checkpoint inhibitors continued to rise through 2020, it did so at a slower growth rate than that of pre-pandemic growth rates.
Aitken also stated that more than one-third of oncologists report that they are providing more support to their patients in discussions on COVID-19. Oncologists report their patients are facing delays in getting appointments, logistical challenges, and financial hardships.
Telehealth's Benefits
On the pandemic silver lining side, Aitken said the rapid growth of telehealth during the pandemic has turned this technology into a staple of cancer care.
"Remote consultations have been used extensively and are expected to continue as a feature of oncologist care," he said. While the use of telehealth has recently drifted down somewhat, oncologists expect that about 20 percent of their consultations will be remote on an ongoing basis.
Other speakers emphasized that the pandemic has shown how telehealth and mHealth (mobile care via data-capturing smartphones and tablets) can help implement a digital strategy to close gaps and improve cancer care delivery. One improvement is that during the pandemic the electronic health record (EHR) evolved from a claims data tool into a communications and education tool, said Jennie Crews, MD, Vice President and Medical Director of SCCA Community and Network Programs at the Seattle Cancer Care Alliance. "The COVID-19 pandemic is driving rapid innovation in cancer care delivery, which will continue to influence how cancer care evolves going forward," she said.
Agreeing was Timothy Kubal, MD, MBA, Senior Medical Director of the Moffitt Cancer Center and Co-Chair of the NCCN Best Practices Committee. Noting that cancer care has evolved in the face of a global pandemic, he noted the EHR itself didn't change much, but what changed was how it was used.
"We've leveraged it for our patients" to improve the interaction between patients and providers, Kubal said, noting that he is still seeing 50 percent of his patients via telehealth and he finds it a benefit. And cancer survivor Gwen Darien, Executive Vice President for Patient Advocacy and Engagement at the National Patient Advocate Foundation, believes the EHR has evolved into a tool for patient empowerment and partnership.
Importance of Prevention & Screening
During a panel discussion on prevention and screenings, speakers emphasized the need for people to resume their regular, recommended cancer tests.
"We need to educate people to get back to their screenings," said Keysha Brooks-Coley, MA, Vice President of Federal Advocacy and Strategic Alliances for the American Cancer Society Cancer Action Network (ACS CAN).
One major silver lining of the pandemic is an increased national effort to get people back into recommended screening routines. Brooks-Coley cited an initiative to resume cancer screening and treatment called "Cancer Won't Wait and Neither Should You," a joint partnership that includes ACS CAN, NCCN, and 75 other cancer organizations.
She noted that the National Cancer Institute has stated that nearly 10,000 excess U.S. deaths from breast and colorectal cancer alone over the next 10 years will occur because of pandemic-related delays in cancer screening and treatment. This estimate does not account for other cancer types and assumed only a 6-month disruption in care, which suggests that actual excess deaths could be much higher.
"We're starting to see people come back to screening," said Crystal S. Denlinger, MD, FACP, Senior Vice President and Chief Scientific Officer of NCCN. But that return is not uniform across population groups.
"We're starting to see a rebound" in screening, but that is mostly in Medicare patients and less so among patients on Medicaid, said Jennifer Malin, MD, PhD, Chief Medical Officer for Oncology & Genetics at UnitedHealthcare. She noted that "preventive care is not tops on your list" for people struggling financially or trying to find work.
Agreeing was Christopher Lathan, MD, MS, MPH, Chief Clinical Access and Equity Officer at Dana-Farber Cancer Institute, noting there has been "a more sluggish response" to the return to screening among marginalized communities, and it has been harder to get them back into routine screening. To do so, he believes it requires outreach efforts that are "active, granular, and proactive."
Highlighting Cancer Disparities
Another silver lining of the pandemic has been the increased emphasis on reducing disparities to achieve health equity in general and health equity in cancer care specifically. "COVID really shed a light on issues that have been around for years," said Brooks-Coley.
Keynote speaker LaShawn McIver, MD, MPH, Director of the Center for Medicare and Medicaid Services Office of Minority Health, said the Biden Administration's concept of the "new normal" is to build health equity through such actions as Executive Order 13985, which establishes health equity as a defining goal of the federal government across its agencies.
"We provide leadership, vision, and direction related to improving minority health and eliminating health disparities," said McIver, noting that her office focuses on the rural/urban divide, as well as on populations in other underserved communities. She noted that among the tools created by her staff includes the Mapping Medicare Disparities (MMD) Tool. Use of this resource, for example, has shown that Black males have a higher rate of prostate cancer than men in other ethnic groups, she noted.
McIver said it is estimated that between 70 percent and 90 percent of health status is governed by social determinants of health, noting that her office is holding stakeholder roundtables this year to include nontraditional partners in discussions of health equity. "Look around your table and see who's missing," she advised in bringing all stakeholders to the discussion.
Agreeing on the importance of social determinants of health in achieving health equity was Shonta Chambers, MSW, Executive Vice President of Health Equity Initiatives and Community Engagement for the Patient Advocate Foundation.
"As we think about elevating cancer equity, we can't ignore the impact of the social determinants of health hindering people's ability to access and adhere to cancer care," she said. "Health care outcomes are not limited to the four walls of the health care systems; we must account for the social context of one's health care and act on tangible solutions to respond to them. That is how we elevate cancer equity for everyone."
As previously reported by Oncology Times, the NCCN, in collaboration with ACS CAN and the National Minority Quality Forum, launched an initiative called Elevating Cancer Equity: Recommendations to Reduce Racial Disparities in Access to Guideline Adherent Cancer Care. The initiative's Equity Report Card makes a number of practice recommendations and policy change recommendations to help ensure all cancer patients receive equitable cancer care.
Clinical Trial Improvements
Yet another silver lining of the pandemic has been the realization that adaptations and innovations in cancer clinical trials can improve efficiency and may result in enrolling more diverse patients.
"We were told for years that we could not do remote consenting," said Lathan. But, he noted, it proved not to be true and "we found we could do it." Lathan added, "What we've learned from the COVID experience is when we want to we are able to recruit diverse patients to clinical trials."
Denlinger agreed on how pivoting during the pandemic increased flexibility and responsiveness in cancer clinical trials. She cited remote patient monitoring, remote data monitoring, and partnering with local laboratories for subject testing as some of the advances in conducting clinical research fostered by the pandemic. These advances should be taken into account in developing research protocols going forward, she said.
Agreeing was Jeff Allen, PhD, President and CEO of the Friends of Cancer Research. He said that adjustments to Institutional Review Board (IRB) reviews and other trial protocols made during the pandemic, along with collaborations, could help improve the efficiency of cancer clinical trials in the future.
"We learned that barriers don't need to be avoided; they can be taken down," said Allen. He cited the power of technology to help identify adverse events early, via passive sensors for data gathering, for example.
"I'm an evangelist for using real-world data...Although we do not yet know the full impact of COVID-19, one clear outcome has been the massive public education on the importance of real-world evidence in clinical trials," said Sarah Alwardt, PhD, Vice President of Operations at Ontada. "We have now reached the tipping point in using real-world data to accelerate trial design and populations. We've demonstrated that this real-world evidence can be trusted and I hope that we ensure this momentum carries forward."
Kubal agreed on the value of pandemic-caused innovations in the conduct of clinical trials. He noted that an important lesson learned during the pandemic is how technological applications can now offer the chance for many more cancer patients to enroll in clinical trials sponsored by the National Institutes of Health (NIH) regardless of the patients' home locations. Not having to leave home to participate in an NIH clinical trial "is better for the patient," he said.
Peggy Eastman is a contributing writer.