Please join us every Friday as Roswell Park experts answer your questions about cancer concerns during the COVID-19 pandemic. We’ll feature a different topic every week, and you’ll have a chance to submit questions in advance or during the live webinar.
This week, Friday, April 17, at 11 a.m., you’ll hear from Boris Kuvshinoff, MD, MBA, Roswell Park’s Chief Medical Officer, and Katherine Mullin, MD, Director of Infection Control and Prevention, who will tackle the topic “Keeping Cancer Patients Safe During COVID-19.” Register here. If you can’t tune in for the live program, you can watch it here later at your convenience.
Last week, John Kane III, MD, FACS, Chair of Surgical Oncology, and Eunice Wang, MD, Chief of the Leukemia Service, answered questions about continuing your cancer treatment during the pandemic. Rebecca Vogt, Media Relations Specialist, moderated the program and shared viewers’ questions with the team. Here’s what they said.
Vogt: We’re hearing from patients who are afraid to leave their homes and come to Roswell Park for treatment. We know there are a lot of uncertainties in this world right now, but the center is taking all precautions necessary to reduce the spread of the virus. That includes reducing the number of employees and visitors who are both on campus and in our satellite locations; sending home staff who were at high risk; aggressively disinfecting all surfaces — and a big shoutout to our Environmental Services team for doing a lot of that! — and limiting entry to clinical buildings; there are only a few entrances individuals can access Roswell from.
But even after all that, we know there are still going to be questions out there. We’re here to answer them.
Dr. Wang: The most important person to have that conversation with is your medical oncologist. Our cancer patients, many of whom are on active chemotherapy, are at higher risk of developing COVID-19 because of their very suppressed immune systems and their ongoing therapy.
However, it’s not 100% certain that you will be infected with COVID-19, but it is 100% certain that if you have cancer, the cancer does need to be treated and fought. At this point we have no idea how much longer the isolation and quarantine situation is going to last — a couple of weeks or months, or even into the summer. So whether it’s safe to delay your cancer therapy over that time period is a decision you and your medical oncologist need to make.
For example, for patients who are already in remission, who are just getting maintenance therapy and don’t need to come in, the discussion would be whether it’s worth it to continue that or not, or how much benefit that’s having.
In my service, I take care of a number of patients with acute leukemia. That’s a very aggressive malignancy, and for many of my patients, it’s not possible to safely hold chemotherapy for a month, two months, three months. For those patients, we are advocating that you still come in to have your cancer chemotherapy treatment, to see your doctor, to have that discussion.
We’re still open for business. For patients whose treatment can safely be delayed or who can safely be seen virtually, we are offering telemedicine — “virtual visit” consultations — to have those discussions.
I would encourage patients to reach out to your clinical center, have a talk with your medical oncologist, and if they feel that you would benefit from continuing your therapy to prevent your cancer from progressing, I would come in. We are taking a number of precautions so we can continue to provide the safest cancer therapy despite the COVID-19 pandemic.
Dr. Kane: All the surgery chairs have been working very closely over the last couple of weeks to develop a system to see new patients, get them in, get their surgery done safely and get them home, while minimizing their risk of exposure to COVID-19.
With a lot of solid tumors — for example, early breast cancer, early GI cancers — if you’re having surgery, that’s often your potentially curative treatment. There’s a little bit of wiggle room to wait for surgery — a few weeks for some people, but for others, not so much.
All of the OR staff now have full personal protective equipment. Now we can operate on somebody whether they’re COVID-positive or COVID-negative, with minimal risk of spreading infection.
We are currently doing COVID-19 testing preoperatively for all patients who are going to have surgery and be admitted to the hospital. We’re doing this because, if there could be a little bit of a delay, say a week or two, it would be very good not to operate on somebody who’s just turned COVID-positive. If they started having respiratory problems two or three days after a big operation, that wouldn’t be good. Even before the COVID-19 pandemic, if you came in for surgery and had the flu, it wouldn’t be safe to put you to sleep, so if we could, we would wait a couple of weeks.
This way we’re testing every surgical patient. We’re doing drive-by testing the morning before surgery. Patients don’t have to get out of their cars. They get swabbed. We have the results by the end of the day, because all the testing’s done in-house. So that gives us the opportunity to delay the surgery if it’s not truly urgent, to give the patient the best chance of recovery.
We’re a cancer center. We have to treat cancer. It doesn’t go away in a pandemic, just like heart attacks and heart disease and trauma don’t go away. But we want to do it safely for all the patients.
Dr. Wang: That’s a case-to-case basis. If you’re a survivor or in long-term follow-up and are not getting active chemotherapy, you might be able to arrange a virtual visit with your provider.
We don’t want you to have high-level anxiety while you’re quarantined at home. (“Is my cancer coming back? When can I see my doctor?”) So we’re encouraging patients, particularly those with blood cancers, to come in and continue to get blood work, either here or at a local lab, and ideally to set up a virtual visit with us, to determine if there are any symptoms or findings and address any concerns you have. We are scheduling outpatients about two or three months out for a regular follow-up appointment, after we have a virtual visit, just to ensure that you’re not falling off the map.
A lot of our patients are concerned about coming to the hospital. But as Dr. Kane mentioned, we’re taking precautions. All the staff are masked. All patients are being provided with a cloth mask. We are restricting access to only essential visitors for our outpatient visits. So if you’re comfortable coming in, we’re happy to do that.
Dr. Wang: Again, I would advocate having a discussion with your primary oncologist, but if you have cancer, sometimes you cannot delay the chemo. You need to get treatment and you can’t wait two, four, six, eight weeks.
Those patients are the reason we’ve made so many efforts to continue to function. We have staff — clinicians and other workers — who come in every day to ensure that cancer patients who need chemo can continue to get chemo despite the COVID-19 pandemic. It’s essential that we not compromise somebody’s care because of the quarantine situation, because when this is over and they come back to us, we don’t want to find out that they have progressive cancer.
Dr. Kane: Absolutely. The traditional model was that you had to come in, we had to see you, poke and prod you, ask you questions. But for a lot of cancers, in that first visit, a lot of the information comes from questions and from scans, biopsies and blood work that you’ve already had. So we have really started to rethink the process of getting people in for their first visit.
For example, I’m seeing a sarcoma patient later today through a virtual visit. I have all the person’s scans loaded into PACS [Picture Archiving and Communication System], I’ve already looked at the scans, I’ve looked at all their records, and we’re going to make a treatment plan without the person having to leave Syracuse.
We’re providing patients with options at this point. If you want a second opinion, if you’re newly diagnosed but caring for someone at home who’s sick, or if you are just very concerned — maybe you have bad lung function, or you’re immunocompromised — we’re doing a lot of virtual visits, as long as we can give you a reasonable evaluation and it doesn’t require touching you or a physical exam.
It’s the same with follow-ups. From the surgical side, if you have a post-op visit and you have a drain in place, we haven’t trusted patients to pull those out themselves yet, so we do have them come in. But I have had some of my patients or their family members take out their sutures if they’re doing well otherwise, to save them a visit. They can send a picture of how their incision is healing.
I would say for a follow-up, it’s really based on risk. We have patients we may follow for 10 years, but we know that the risk of their cancer coming back is very low when they’re five or six years out and we’re seeing them only once a year, so we can put that visit off two or three months.
If somebody just had surgery three months ago and this is their first visit for their follow-up, then we may not be able to do that. But we’re being very thoughtful about it. We’re doing what is best for the patient, what is safest for the patient, and whatever we need to do to make that happen safely, we’re doing it.
Any time something bad happens in the world, sometimes there are some good consequences. I think this idea of social distancing in the pandemic is going to change how we manage health care, and I think one of the big things is going to be virtual visits. Virtual visits are also going to be very important at Roswell Park because not all our patients come from Western New York. We have patients coming from other parts of the state, other states and even other countries.
Dr. Kane: Again, it depends on the situation. For example, we may give “insurance” radiation — what we call “adjuvant” radiation — after the tumor has been removed. Often that can wait several weeks. In fact, we would typically wait until the person was better from their operation before we started it. If they had some postoperative recovery issues, that would delay it. If we’re giving it first, before we do surgery, there’s a little bit of a window, but you really don’t want the tumor to keep growing. So for some aggressive tumors, having the patient get started in a timely manner would be very important.
We are providing care with the fewest number of providers touching the patient. So when I saw two new patients this morning, it was just me. I didn’t have a resident or fellow go in first. They saw one nurse. Non-essential staff are staying home.
So even though you have to come in for radiation treatment every day, they have it set up where you’re not contacting very many other care providers or patients. They’re staggering the appointments, so you’re not sitting in the waiting room with 20 other people. They’re allowing extra time to clean the rooms, the radiation machines, the CAT scanners, and things like that.
This has really been thought out, so if you need cancer treatment, it’s going to be as safe as possible, with a minimum number of people touching you.
Dr. Wang: At the present time, because of the number of people who may be infected without having symptoms, we are discouraging significant numbers of visitors accompanying patients. There may be exceptions: Certainly for a new patient visit, you need somebody to be there to listen to the treatment plan. Some of our patients need drivers to accompany them or maybe help with a wheelchair or walker. Certain patients may have neurological issues that require a caregiver. But part of social distancing means not having a family of five coming in for an appointment.
How are we dealing with that? We know you want people to be with you, so we are using technology to call or Facetime or reach out to have video chats, so we can include the family members when talking about the care of the patient. Our inpatients are being provided with iPads so they can video chat with their loved ones.
We certainly don’t want that isolation to be a source of anxiety. But we also need to be aware that many of our patients are uncomfortable coming to the cancer center. I’ve had patients tell me the only time they leave the house is to come for their cancer follow-up appointments or to get chemotherapy. So when they come here, they don’t want to see a large crowd of people in the lobby, and we are cognizant of that.
We try to minimize groups of people. If you feel safer going to facilities closer to your own home for blood work, to minimize travel time and minimize exposure time, do that, and follow up with your Roswell Park caregivers here.
Dr. Kane: We’ve taken a similar approach with surgery. If you’re newly diagnosed with cancer and you’re coming in for that initial visit, I think it’s very difficult to be by yourself. So, for example, the two new patients I saw this morning face-to-face each brought one caregiver with them.
For follow-up visits, if you’re an established patient, we ask the person who accompanied you to wait outside. Again, we’re trying to protect all the patients, not just one particular person, and we don’t want to fill the waiting rooms.
One thing that has been a little difficult for the post-op patients is that visitors are not allowed on the floors. But if you just had a major abdominal surgery, it’s really in your best interest for your friends to stay home. If they’re asymptomatic carriers of COVID-19, you could develop a respiratory infection, and it could mean the difference of not making it out of the hospital or going to the ICU for a long stay.
Dr. Wang: Obviously I can’t guarantee what types of precautions are being taken at your local Quest, but in many cases, if you’re taking a chemo pill and you have a low blood count, you need your blood counts monitored. You need to make sure your counts are not falling to a dangerous level. You may need a transfusion. If you’re on a chemo pill and you’re being monitored for side effects and toxicity, it’s very important that you continue getting that blood work. Again, that means a phone call or a text or a message to your oncologist. If your local lab can do that safely, and you want to save yourself a visit here, I think that would be fine.
Our phlebotomy services are open here. Again, everybody is being screened coming into the facility, everybody’s wearing a mask, all the healthcare workers — including the phlebotomists — are all wearing masks. So if you want to stop in and get quick blood work and then do a virtual visit, that would be fine. But it’s important not to delay or not to get chemotherapy because of COVID-19, because when this is over, we don’t want to see our patients having had less than the standard of care therapy.
During this pandemic, we have put aside our research and educational missions to focus on continuing to provide the very best cancer care for our patients.
Dr. Kane: We’ve taken a very measured approach with that. Our radiologists here are phenomenal. They look at cancer studies all the time. We have state-of-the-art imaging equipment. We have some things, like a PET CT, that many other places don’t.
As surgeons, we look at scans all the time; that’s how we plan the operation. We’ll often coordinate that CAT scan visit with a follow-up visit. You might get the scan at 10:00 and see us at 11:30. It saves you from having to go back and forth, because we’re going to have to look at it ourselves anyway.
We’re still having local patients get their CAT scan here, even if we’re doing a virtual visit, but it doesn’t make sense for a patient in Oswego to drive here for a CAT scan and go home and then have a virtual visit. So in those situations, we’re often asking, what would be the local facility that you would go to? You would get a CAT scan there. It takes a day or two to get it loaded into PACS. We look at it and then we have a virtual follow-up, after seeing that CAT scan.
Dr. Wang: The concern with vaccines is that they work by stimulating your immune system to recognize and destroy any infections coming into your body. We do think that patients who are immunosuppressed from their cancer therapy are probably not the best candidates for vaccine therapy.
Dr. Kane: Our primary job is to take care of people with cancer. Even in the middle of the COVID-19 pandemic, people are still going to get cancer. We have come up with strategies and pathways to minimize your risk of being exposed to COVID-19 or exposing somebody else.
Whether you have a new cancer, you’re actively on cancer treatment or you’re in your follow-up phase and doing well, we’re prepared to give you the best possible cancer care while minimizing your chances of potentially being exposed to COVID-19.John Kane III, MD, FACS
Dr. Wang: Roswell Park has been a beacon of cancer care in upstate New York for more than a century. We’re continuing that mission now, even in the face of the COVID-19 pandemic.