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July 2, 2020

Covid-19 Pandemic—An Opportunity to Reduce and Eliminate Low-Value Practices in Oncology?

Author Affiliations
  • 1Department of Oncology, Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
  • 2Cancer Research Institute, Division of Cancer Care and Epidemiology, Queen’s University, Kingston, Ontario, Canada
  • 3Department of Hematology-Oncology, Civil Service Hospital, Kathmandu, Nepal
  • 4Queen’s University, Kingston, Ontario, Canada
JAMA Oncol. 2020;6(11):1693-1694. doi:10.1001/jamaoncol.2020.2404

The coronavirus disease 2019 (COVID-19) pandemic has brought critical challenges to the practice of oncology in many high-income countries (HICs) such as the US and Canada. Measures are now being taken to reduce the flow of patients to cancer centers and hospitals by substituting electronic or telehealth visits for in-person visits wherever feasible, reducing the frequency of follow-up visits, reducing surveillance imaging and other tests, and engaging in discussions about which are the most important anticancer therapies to deliver, if and when capacity to provide treatments become reduced. These are just a few of the measures being taken by health care institutions and physicians to minimize face-to-face patient visits to control the spread of COVID-19 and to optimally deploy health care workers in the health system. These are obviously rational steps to take during a pandemic, especially as new data suggests that patients with cancer may be at a higher risk of death with COVID-19 infections, although there are some uncertainties about the reliability of this information.1

Could this new wave of awareness to identify and discourage unnecessary in-person visits, testing, and low-value treatments provide a lasting benefit to our cancer systems beyond the pandemic period? The necessity to change, adapt, and innovate created by the COVID-19 pandemic may yield a more lasting series of changes that can help address overstretched, costly, and at times inefficient cancer care systems. It is evident that, going forward in the post–COVID-19 world, there will be severe economic residua of the lockdowns and restrictions imposed to curb the pandemic, and saving precious health care resources and funding will be a priority. Thus, decisions made during this period will be an opportunity to identify and discourage low-value practices in oncology.2

The concept of “value-based cancer care” has garnered a great deal of attention in recent years. Although in some jurisdictions, the oncology community and regulatory authorities have favored access to and approval of new cancer drugs based on intermediate end points, others have argued that there should be clear evidence of improvement in survival or quality of life, particularly when most such new therapeutics come at substantial cost. At this time of pandemic, however, we are seeing a coming together of many in the oncology community to reevaluate the priority therapies to be offered to patients: focusing on those that clearly improve outcomes in a meaningful way that justify the increased risks to patients of coming to hospitals to receive treatment.3 It will also be important to observe if patient decision-making is affected: the minimal absolute gains of some standard therapies (eg, some adjuvant situations where recurrence risk is relatively low; third- or fourth-line metastatic disease treatments), may be weighed by patients negatively given the risk they perceive to their health in attending clinics during the pandemic.

Several authorities have issued guidelines on treating cancer during the COVID-19 pandemic, with a common theme among them using a priority-based approach to cancer care. Cancer Care Ontario provides priority levels A to C recommendations, with recommendations to continue the standard treatment for priority A category, delay until the pandemic is over for category C, and to make the individualized decisions for patients in category B.4 The National Health Services in the UK has issued guidance for prioritization in 6 levels based on treatment success rates where curative therapy with a high (>50%) chance of success receives a priority level 1 and priority 6 is for noncurative therapy with an intermediate (15%-50%) chance of palliation or temporary tumor control and less than 1 year of life extension.5 The American Society of Clinical Oncology has also issued a resource suggesting a case-by-case approach to assess whether treatments could potentially be delayed or stopped without compromising clinical benefit.6

In real-life terms, some oncologists have stopped prescriptions for drugs where the clinical benefit is small but the chances of severe adverse effects requiring hospitalization are high. Indiscriminate off-label use of targeted therapies based on genomic alterations have slowed down. Even immunotherapy use has been reserved for cancers such as melanoma or lung cancer where the benefit is substantial. The National Health Services UK guidance also suggests increasing the interval of immunotherapy regimens to 4 or 6 weekly rather than 2 weekly. Indeed, it is time for us to seriously consider evidence for every treatment regimen to make sure the benefits outweigh the risks.

In fact, although we are facing these decisions suddenly in HICs owing to the pandemic, such priority-setting exercises are already well established in less wealthy countries across the globe. The WHO-Essential Medicine List is an example that has been helpful for low- and middle-income countries (LMICs) to decide which drugs to ensure are available. Our change in thinking in terms of priorities driven by the urgency of the pandemic reality is, in fact, everyday routine oncology practice in LMICs. That is one of the reasons this pandemic has not brought as much panic to oncology specialits in LMICs as we would imagine it to bring given the degree of alarm surrounding these discussions in resource-rich countries. In a sense, although LMICs have been functioning in a resource-limited setting every day, the COVID-19 pandemic has suddenly forced HICs to adopt some of the same approaches to decision-making in a way that is entirely new to them.

Some colleagues on social media raised a question about whether women should be undergoing screening mammography during the pandemic. The answer from most colleagues was a resounding “no.” We argue that we need to take it a step further—not just for mammography screening in particular, but for every intervention in oncology or medicine—and consider if we should do it even if there is no pandemic. We believe this is an opportunity to choose wisely, be thoughtful, and critically appraise the evidence for everything we do as physicians.

We do realize that thinking in terms of value or priorities may slowly fade away once the pandemic recedes and the pressure to make these critical decisions wanes. However, it would be a mistake to dismiss the careful and thoughtful decisions about how we deliver cancer care and what treatments we prescribe during this pandemic crisis as short-term changes only. They represent an opportunity to rethink how our cancer system should function using meaningful patient outcomes and value at the center of decision-making. If we revert to practice as usual postpandemic with testing, imaging, and treatments, we would have lost the opportunity to learn from the lessons this pandemic has brought to the fore. The ability to work and adapt to working in a resource-limited setting is an important skillset for us all to develop. Truly, no matter where we work, we are all global oncologists because at the time of pandemic, we are all resource limited.

The COVID-19 pandemic and our global response to it is the defining public health crisis of our time. Let us learn from it—not only about how to manage global infectious disease threats that will come in future, but also about what in oncology and other areas of medicine are the important interventions, with outcomes of meaning to patients, that we should focus on delivering .

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Article Information

Corresponding Author: Bishal Gyawali, MD, PhD, Cancer Research Institute, Division of Cancer Care and Epidemiology, Queen’s University, 10 Stuart St, Level 2, Kingston, ON K7L 3N6, Canada (bg.bishalgyawali@gmail.com).

Published Online: July 2, 2020. doi:10.1001/jamaoncol.2020.2404

Conflict of Interest Disclosures: None reported.

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