Pent up demand for cancer screenings, diagnostic workups, and treatments delayed or curtailed since the start of the pandemic is expected to result in a surge of patients—some with more advanced disease as a result of delays—seeking appointments with oncologists.
“It is going to be important for physicians to recognize that previous schedules are not going to work now. Unfortunately, there will be a necessity to triage patients a bit.”— Barbara L. McAneny, MD, MACP, FASCO
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“We are starting to see the increase of oncology visits now, and we have recognized there will be a lot more patients with cancer who need to get in,” Barbara L. McAneny, MD, MACP, FASCO, cofounder and Chief Executive Officer of New Mexico Oncology Hematology Consultants/New Mexico Cancer Center in Albuquerque, said in an interview with The ASCO Post. Dr. McAneny is also a past President of the American Medical Association (AMA) and a former member of the ASCO Board of Directors, although she stressed during the interview that she was speaking as a practitioner and not as an AMA or ASCO representative.
More Advanced Disease
A recently released survey conducted by the American Society for Radiation Oncology (ASTRO) found that 66% of physicians reported that patients are presenting with more advanced cancers.1 Dr. McAneny has seen that in her practice as well. For example, a patient with COVID-19 “had a palpable mass in her breast for a year and had not been able to get a mammogram,” Dr. McAneny reported. “When she came to us, she had a pretty sizable cancer.”
A recent weekly tumor board meeting reviewed the case of a patient whose concern about COVID-19 caused him to delay seeking medical attention for symptoms of rectal cancer. “He is struggling with that now because he has a more advanced cancer,” Dr. McAneny said.
Due to the expected surge, “it is going to be important for physicians to recognize that previous schedules are not going to work now. Unfortunately, there will be a necessity to triage patients a bit. For example, if someone has a long-standing coagulopathy and wants a second opinion, then that patient may need to wait so we can get patients with cancer in sooner. If someone has an iron deficiency anemia, we may conduct a quicker visit to get that person started on treatment but save time for oncology patients,” Dr. McAneny stated.
“Every practice, whether academic or independent, needs to be considering how they are going to restructure their workload to accommodate this wave of patients who, frankly, are going to take longer than the usual 1 hour we had scheduled for a consultation before,” Dr. McAneny continued. “We are seeing patients who say, ‘I didn’t show up because I was afraid of COVID, and I knew this was a problem.’ They are feeling very remorseful, and it takes time to take care of them emotionally when they know their prognosis is worse because of the delay.”
Telemedicine Visits
Earlier in the pandemic, Dr. McAneny and colleagues had run a campaign using the motto, “Cancer doesn’t wait for COVID,” and the message, “If you’re concerned that the symptoms you have might be cancer, please call us and schedule a telemedicine visit.”
The telemedicine visit is used to determine whether a person responding to the message has cancer concerns that require an in-person visit. “Usually, we accept patients by referral from other physicians, so we know they truly have cancer,” Dr. McAneny noted. “But we didn’t know if we were going to get people who are seeking pain medication or who really are not appropriate for us to be taking care of. If the patients are worried, we try to get them to the right place, but we don’t necessarily need to have oncologists see them because we have a shortfall of oncologists anyway.” [See sidebar on page 103.] Callers who have concerns that might indicate cancer can make appointments for an office visit.
“We never saw a decrease in our radiotherapy volume…. We have the advantage of being a community practice. We are not in a hospital, and I think that has assured a lot of people.”— Barbara L. McAneny, MD, MACP, FASCO
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“We basically feel that we need to see these people in person to do a good job of cancer consultation. You can’t really conduct a good cancer visit over the phone or by telemedicine. You can’t really look at that mole. You can’t feel that lymph node,” Dr. McAneny commented.
“We use telemedicine, but we also see people in person,” Dr. McAneny noted, and that is one of the reasons “we have seen a couple of waves of new patients,” she said. “Many of the practices that were hospital-based were limited to telemedicine. Patients disliked that. They wanted to actually be seen in person” as well as avoid hospitals due to COVID-19 concerns.
In a recorded interview available on her practice’s website, Dr. McAneny stated that the practice would continue to take and treat new patients and that it is the duty of practices not to overburden hospitals focusing on COVID-19.
‘We Follow the Science’
Patients who do come in for an office visit are carefully screened for exposure to the coronavirus. “We operate on the principle that everyone we see probably has COVID-19. It is the only safe way to operate,” Dr. McAneny said. “We have them in masks. We are in PPE [personal protective equipment]. If somebody has respiratory symptoms or any symptom of the disease, then we add the face shield.”
The ASTRO survey found that many of the responding radiation oncologists had difficulties obtaining adequate supplies of PPE, with 42% still reporting shortages. Dr. McAneny said that she also had problems obtaining PPE in the beginning of the pandemic, but then the AMA “stepped up” and created a project to facilitate the process of distributing PPE to physicians across the country. “As a result, we have done okay,” Dr. McAneny said. “We have not had problems.”
Patients generally adhere to and appreciate the safety precautions. “We have had an occasional patient who wants to say this is a political thing or a hoax. We say, ‘We are a private business. It is our choice that we will treat people if they have their masks on. You are most welcome here if you wear your mask and follow our precautions.’ Most people have said that makes perfect sense. We point out to those very few other patients that it is not their own lives they are putting in danger, but everyone else’s life, and that is not acceptable. We follow the science.”
Family members, friends, or others who bring or accompany a patient for visits are generally asked to wait in their cars. “Our policy has been that if people need help walking or thinking, we will let a family member or caregiver come in with them, assuming that person does not have a COVID-19 symptom. Everyone has to have a mask on to be allowed in the building,” Dr. McAneny stressed.
“Most people, fortunately, have smart phones,” she added. “The doctor can be talking to the patient, and the person in the car can participate by FaceTime or just by phone and be part of that consultation without coming into the building.”
Keeping It Clean
Dr. McAneny credited the cleaning staff for their work in keeping the facilities safe. “Cleaning is happening constantly,” she said. For patients with a high suspicion for COVID-19, “we have a process where we decontaminate the exam room they were in. We’ve set up isolation rooms for people who need to be seen and might have COVID-19. For example, if you have a patient who calls in with a fever, a lot of places are saying ‘Go get a COVID test, and see me tomorrow if it is negative.’ The problem is that, if you have patients with neutropenic fever and send them home for a day, their chances of surviving that neutropenic fever have diminished a lot,” Dr. McAneny said.
“The basic underlying assumption of treating all patients as if they had COVID-19 and acting accordingly has worked well for us.”
Aggressive Cancers
Patients with aggressive cancers may require more frequent office visits, but “if you do not treat them, you miss a chance for a cure. The way we present that to patients,” Dr. McAneny said, “is, if we don’t treat the cancer, you know what will happen. This cancer will progress, and it will end your life.” She asks patients to “balance that against the possibility of COVID-19.”
“We actually work very hard to try to get our patients vaccinated. We wanted to be a vaccine center. That never panned out in New Mexico, but New Mexico has done a very good job of getting people vaccinated,” Dr. McAneny remarked.
“If you have a pocket of people who have been denied access to health care, vaccines, and the ability to control infections, you are putting everybody at risk, not just that population.”— Barbara L. McAneny, MD, MACP, FASCO
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“We are very proactive about monitoring patients who are receiving chemotherapy,” she added. “If they develop a fever, we bring them in, put them in the isolation room, and have staff clinicians in full PPE see them. We give them intravenous antibiotics and everything they need because we don’t want them to go to the hospital. So far, we have not had to admit people to the hospital with neutropenic fever,” she noted.
The ASTRO survey found that physician-reported rates of treatment deferrals were 75% in April 2020, compared with only 12% early this year. In contrast, Dr. McAneny reported, “We never saw a decrease in our radiotherapy volume. I know that across the country, many facilities did. We have the advantage of being a community practice. We are not in a hospital, and I think that has assured a lot of people.”
Deductibles and Copays
An article in The New York Times on delayed screening and treatment during the pandemic reported, “the downturn in the economy has also discouraged many people from seeking help or treatment.” That applies even to patients who have insurance but can’t afford the deductibles, Dr. McAneny commented in the Times article. “We’re seeing that particularly with our poorer folks who are living on the edge anyway, living paycheck to paycheck.”2
Dr. McAneny supports the restructuring of the health-care exchange to allow more people to get plans through the Affordable Care Act. She also favors restructuring the exchange plans “so they have reasonable deductibles. Deductibles and copays were designed to keep patients from undergoing unnecessary tests. The literature has shown that they keep patients from doing both necessary things and unnecessary things,” Dr. McAneny noted. “Maybe it is time to rethink whether copays and deductibles are serving the function we had hoped they would serve and perhaps do a redesign of insurance.”
‘We Are All in It Together’
“The pandemic makes it clear that, if you live on this planet, we are all in it together—if you have a pocket of people who have been denied access to health care, vaccines, and the ability to control infections, you are putting everybody at risk, not just that population,” Dr. McAneny commented.
“Viruses do not respect borders, and mutations tend to become more prolific in areas where people are jammed close together and do not have the luxuries of affluence. Therefore, poor people and people of color have been incredibly hurt by this pandemic. If we do not take care of them, we will have cause to regret it, not just morally, but actually physically.”
Dr. McAneny praised the Navajo Nation for doing “an incredible job of getting their people vaccinated. They were devastated by this because, if you don’t have running water, electricity, and smart phones to do telemedicine, or broadband so you can even consider telemedicine, then you are at high risk of being impacted by the virus. We saw entire families die.”
Although some people were “a little suspicious of Western medicine, the Navajo Nation and Navajo Nation President Jonathan Nez have done a remarkable job of letting their people understand that these vaccines are there to protect them,” Dr. McAneny said. She also credits the Indian Health Service, which she said, “is chronically underfunded but has remarkable people who are the masters of getting things done without adequate resources.”
New Mexico Oncology Hematology Consultants has a clinic in Gallup that provides cancer care to the Navajo Nation and others who live in that area and has continued to treat patients with cancer throughout the pandemic.
DISCLOSURE: Dr. McAneny has been employed by the AMA, Innovative Oncology Business Solutions, and New Mexico Cancer Center; has served in a leadership role for the AMA, Innovative Oncology Business Solutions, and New Mexico Cancer Center; holds stock or other ownership interests in Innovative Oncology Business Solutions and New Mexico Cancer Center; holds institutional intellectual property in Innovative Oncology Business Solutions; has been reimbursed for travel, accommodations, or other expenses by the AMA, ASCO, COA, Innovative Oncology Business Solutions, and New Mexico Cancer Center; and has held other relationships with the AMA and National Cancer Care Alliance.
REFERENCES
1. Sternberg A: ASTRO survey of radiation oncologists shows treatment delays, health disparities resulting from COVID-19 pandemic. American Society for Radiation Oncology press release. March 31, 2021.
2. Abelson R: Advanced cancers are emerging, doctors warn, citing pandemic drop in screenings. The New York Times. March 17, 2021.
