ASTRO: Amid COVID-19, PPE Shortages, Fewer Visits, and New Ways to Fight Cancer

A new survey from the nation’s radiation oncologists reports shortages of personal protective equipment (PPE) and a drop in the number of patients due to the coronavirus disease 2019 (COVID-19) pandemic.

The findings from the American Society for Radiation Oncology (ASTRO) highlight the growing financial strain at freestanding clinics, including those that say they will lose half their annual revenue. Some freestanding clinics are the only location for radiotherapy in their area.

But the ASTRO report also shows the radiation oncologists’ ability to adapt, whether it was through telehealth or other care delivery models. In mid-April, ASTRO and its European counterpart published recommendations for treating lung and head and neck cancers during the pandemic. During an interview with The American Journal of Managed Care®, ASTRO President Thomas Eichler, MD, FASTRO, said the recommendations, which appeared in separate journal papers,^1,2 will be especially helpful to community clinics—and will be in place if there is a resurgence of the virus in the fall, as many public health experts fear.

“That was a fascinating process,” Eichler said. For both papers, “From inception to publication was less than a month,” compared with a normal guidelines process which takes 12 to 18 months. The process began when Eichler’s counterpart from the European society asked if ASTRO wanted to take part in developing recommendations to be used during the pandemic for lung cancer.

“We said yes, immediately,” Eichler said. Within days, ASTRO presented a similar offer to develop recommendations for head and neck cancer. The panels used a system in which experts from both organizations voted on a series of questions, which resulted in the papers.

Eichler said he is pleased that the survey remains in the field and will continue to gather data from physicians over time. The same survey is being used to collect data from physicians in Europe, Canada, Latin American, and Africa, so over time ASTRO and its international counterparts will have data to compare the effects of COVID-19 on the profession.

What the ASTRO Survey Found

The ASTRO survey reached 222 physician leaders during April 16-30; Eichler said steps were taken to ensure that the survey did not reach multiple physicians at the same practice. All the physicians reached said their practices were still offering services during the early weeks of the pandemic, but 85% reported fewer patient visits, with an average decline of one-third.

All practices said they would lose revenue, mostly due to fewer patient visits and deferred or delayed treatment (82%). Typically, practices said they would see revenue drop 21% to 30%, but the pain in freestanding clinics was worse: 1 in 5 said they would lose more than half their annual revenue due to the pandemic.

These losses mounted despite steps practices took to make visits safe:

• 99% required masks for staff
• 83% required masks for patients
• 98% screened patients at the clinic door
• 98% used social distancing
• 90% do not allow visitors

As seen across health care, ASTRO respondents reported problems obtaining PPE, with 69% saying they experienced limited access or shortages. In fact, AMGA (the American Medical Group Association) reported its own survey this week that PPE shortages remain a top concern among members, and many practices continue to order supplies in 2-week increments.

Eichler said the shortages of PPE reported in the survey stood out to him as “appalling.”

“Really? This is really happening in the United States?” he said. For Eichler, is hard to accept that in an advanced health care system “that we don’t have enough masks and gloves and hand sanitizer to go around. That’s just beyond belief.”

ASTRO warns that the accumulated missed visits at freestanding radiotherapy clinics could put some out of business, because the emergency financial relief offered by Congress may not be enough to keep some of them open. The reduced visits are translating into job losses: as the majority of practices reported staff reductions due to declining patient volume (49%), increased family care responsibilities (28%). Reductions due to COVID-19 illness among staff were limited (11%).

When it comes to freestanding practices, especially in a rural area, Eichler said, “You have to think of these not as a medical practice but as a small business. If your Mom and Pop gas station had a 50% decrease in revenues, they go out of business. We’ve seen that across the country. …

“One of the real fears here is that in the smaller, rural practices, where they have one doctor and 2 technicians—maybe they’re doing their dosage support remotely—if somebody gets sick in that practice … if they can’t make up that revenue, they’re going to close, and then that community is in big trouble down the road.”

Telehealth and Other Effects of COVID-19 on Cancer

The ASTRO survey found that telehealth has become an essential method of care delivery, and radiation oncologists adapted quickly: 89% of respondents reported offering this option for consults or follow-up visits. Like others across health care, Eichler expects that telehealth is here to stay. But CMS must offer more guidance. “We don't have telemedicine in our set of codes at all,” he said.

In the near term, does Eichler expect any other care delivery changes?

There might be some instances in which we will see hypofractionation, when oncologists use larger daily doses of radiation to achieve the same biologic effect as smaller doses over a longer period of time.

He agrees with the observation that the dearth of screenings and surgeries in the current quarter will almost certainly lead to an increase of diagnoses of late-stage cancers in the third and fourth quarters of 2020, which will be harder to treat.

“It will almost certainly lead to more expensive treatment,” he said; some patients who might have avoided chemotherapy will now need it. Eichler warns this could lead to more surgical patients than the system can accommodate in the second half of 2020, “when all of a sudden, the floodgates open.”

An overlooked aspect of the pandemic on cancer patients is the “huge psychological impact,” Eichler said. A person already has cancer, and “now they may be exposed to this terrible coronavirus.”

A recommendation may say that it’s safe to delay treatment for an early stage breast cancer, but that doesn’t eliminate the stress on the person, he said—considering the psychological impact of, “I’ve got cancer, and it’s not being treated.” And at the same time, he said, nurses and radiation technicians “are on the front line every day,” taking care of patients.

“I'm hopeful that we're doing an adequate job of meeting the needs of not only the patients and the staff, but the membership as a whole. And I will say that we are a long way from this being over.”

References

1. Thomson DJ, Palma D, Guckenberger M, et al. Practice recommendations for risk-adapted head and neck cancer radiation therapy during the COVID-19 pandemic: an ASTRO-ESTRO consensus statement. Int J Radiat Oncol Biol Phys 2020;S0360-3016(20)31034-8. doi: 10.1016/j.ijrobp.2020.04.016
2. Guckenberger M, Belka C, Bezjak A, et al. Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: an ESTRO-ASTRO consensus statement. Radiother Oncol 2020;S0167-8140(20)30182-1. doi: 10.1016/j.radonc.2020.04.001