How Will Patients With Cancer Fare During COVID-19? Many Unanswered Questions | Oncology | JAMA Oncology | JAMA Network
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Editorial
December 3, 2020

How Will Patients With Cancer Fare During COVID-19?Many Unanswered Questions

Author Affiliations
  • 1Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
JAMA Oncol. 2021;7(2):195-196. doi:10.1001/jamaoncol.2020.6085

The coronavirus disease 2019 (COVID-19) global pandemic has placed unprecedented pressure on health care systems; since March 2020, there have been more than 7 million cases of COVID-19 and 200 000 deaths due to COVID-19 in the US alone.1 Previously, for the United States, the very idea of scarce health care resources was more of a theoretical worry than an actual problem. However, with the COVID-19 experience of New York City and models predicting that demand would outstrip supply for critical components of our health care system including personal protective equipment, respirators, medications, and health care professionals, the possibility of scarcity has become a harsh reality.

Long before COVID-19, in response to local crises such as Hurricane Katrina and the 2009 H1N1 pandemic, many states developed crisis standards of care (CSCs).2 Crisis standards of care document the principles by which health care professionals will allocate scarce resources, typically prioritizing “urgency of need, the likelihood and anticipated duration of benefit, and the change in quality of life.”3 Resource allocation within CSCs begins with the utilitarian principle that some patients must be prioritized over others to save the maximum number of lives, and that critical resources should go to those who will benefit the most. Determining who benefits the most, however, is both ethically and politically fraught. If applied, the triage process will be unlike anything that the US has experienced. The ethics of applying CSCs are widely discussed and emphasize the importance that for any application to be fair it must have a transparent decision-making process and consistent application and be proportional with the degree of resource scarcity.4

In this issue of JAMA Oncology, Hantel and colleagues5 report that patients with cancer are frequently among those judged to benefit less from clinical resources. The authors extracted data from 31 state CSC guidelines to assess how care for patients with cancer could be affected during the COVID-19 pandemic if the plans were to be fully implemented. They found that 17 CSCs deprioritize certain patients with cancer relative to other groups, and 8 CSCs specifically exclude patients with cancer from receiving care in the presence of scarcity. For example, Oregon’s CSC states that “Based on the goal to maximize the number of lives saved in a sustained public health crisis, people with confirmed advanced disease [including cancer] or severe injury for which the average life expectancy is less than six to twelve months will be referred to less aggressive care rather than aggressive, critical care.”6 Pennsylvania’s CSC states that patients with significantly decreased long-term survival, such as those with metastatic cancer, should receive only palliative treatments.7 A clear challenge of the CSCs is that they frequently lack sufficient precision to guarantee that all interpret the guidance consistently.8 For example, Pennsylvania’s CSC does not specify whether “palliative” is to be considered synonymous with “hospice” or with “a care approach that emphasizes quality of life while still offering disease-modifying therapies.”

Scenarios of extreme scarcity—such as that seen in New York City in the early days of the pandemic—have thankfully not played out across the rest of the country to date, and thus few states have fully implemented their CSCs. Regardless of whether any of the cancer-deprioritizing plans are ever implemented, the treatment of cancer in CSCs points to a fundamental misunderstanding among policy makers of the dramatic variation across cancers in terms of survivability and whether treatment of advanced cancer is, in fact, a poor use of scarce resources. For example, 27% of women diagnosed with breast cancer at a late stage survive for 5 years, and 74% of men diagnosed with testicular cancer at a late stage survive for 5 years.9 Although Lance Armstrong may be discredited in the cycling world, he is also very much alive in spite of a 1996 diagnosis of metastatic testicular cancer. Even pancreas and lung cancers, with their recognized poor prognoses, have 5-year survival rates above 2%. Variability across cancers in survival with late-stage disease should not be surprising. Cancer is not a single disease; many patients diagnosed with late-stage tumors should be offered treatment rather than an immediate referral to hospice care. The limited available literature is clear: there are few, if any, reliable tools to predict an individual’s life expectancy that are precise enough to be the basis for delaying or denying treatment. By applying a blanket deprioritization—or even outright exclusion—to patients with cancer, CSCs could result in patients who could expect to survive 1 or more years having their care cut short or even terminated entirely.

In the face of variation in survival with late-stage cancer, we understand the finding by Hantel and colleagues5 that states with National Cancer Institute–designated Comprehensive Cancer Centers are less likely to exclude patients with cancer. National Cancer Institute–designated Comprehensive Cancer Centers often hold a “seat at the table” in health policy making and can help ensure that patients with cancer are not treated with too broad a brush. Being “at the table” also provides an opportunity to explain to others also at the table that not all late-stage cancers are the same, and not all patients with similar stages of cancer have the same life expectancy. Simply stated, patients with cancer can and do surprise us—and that is good. It is important that our resource allocation plans recognize and allow for this.

Although the kind of scarcity requiring CSCs to go into full effect has not yet occurred, the pandemic has dramatically curtailed health care provided in both inpatient and outpatient settings. Many states restricted elective procedures early in the pandemic, and fears that patients might contract COVID-19 while visiting health care facilities have contributed to record reductions in health care use.10 There have been reports of declines in mammography of up to 90% and delays in elective (ie, scheduled) surgeries.11,12 It will likely be years before credible estimates are available about whether COVID-19–related cancer treatment delays led to increased mortality. Although efforts to flatten the curve have allowed most communities to avoid being overwhelmed, anticipatory closures will surely have a price and it may well be at the expense of patients with cancer. These trends suggest that even though many of the guidelines in CSCs may not have been put into effect, their impact will, nonetheless, be felt by patients with cancer.

As a group, patients with cancer can be vulnerable to the significant shifts in the health care delivery system brought on by COVID-19. The impact of delayed or denied screenings and diagnostic workups as well as suboptimal or delayed treatment may take years to fully reveal themselves. However, the potentially significant impacts on patient outcomes go well beyond those called for in some state CSCs. We must be vigilant in our efforts to take care of our current and yet to be diagnosed patients with cancer or they will risk becoming additional, unnecessary deaths caused by COVID-19.

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Article Information

Accepted for Publication: October 9, 2020.

Published Online: December 3, 2020. doi:10.1001/jamaoncol.2020.6085

Corresponding Author: Beth A. Virnig, PhD, MPH, Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St SE, MMC 729, Minneapolis, MN 55455 (virni001@umn.edu).

Conflict of Interest Disclosures: None reported.

References
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New York Times. COVID in the U.S.: latest map and case count. Updated October 22, 2020. Accessed October 30, 2020. https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html
2.
Committee on Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations; Institute of Medicine. Crisis standards of care: a systems framework for catastrophic disaster response. National Academies Press; 2012. PubMed
3.
American Medical Association. Crisis standards of care: guidance from the AMA Code of Medical Ethics. Updated April 5, 2020. Accessed October 30, 2020. https://www.ama-assn.org/delivering-care/ethics/crisis-standards-care-guidance-ama-code-medical-ethics
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Institute of Medicine Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations; Altevogt BM, Stroud C, Hanson SL, et al, eds. Guidance for establishing crisis standards of care for use in disaster situations: a letter report. National Academies Press; 2009. doi:10.17226/12749
5.
Hantel  A, Marron  JM, Casey  M, Kurtz  S, Magnavita  E, Abel  GA.  US state government crisis standards of care guidelines: implications for patients with cancer.   JAMA Oncol. Published online December 3, 2020. doi:10.1001/jamaoncol.2020.6159Google Scholar
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State of Oregon. Oregon crisis care guidance IDSO. Published March 2014. Accessed October 30, 2020. https://www.researchgate.net/publication/265302083_Oregon_Crisis_Care_Guidance_IDSO
7.
State of Pennsylvania. Interim Pennsylvania crisis standards of care for pandemic guidelines. Version 2. Published April 10, 2020. Accessed October 30, 2020. https://www.health.pa.gov/topics/Documents/Diseases%20and%20Conditions/COVID-19%20Interim%20Crisis%20Standards%20of%20Care.pdf
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Cleveland Manchanda  EC, Sanky  C, Appel  JM.  Crisis standards of care in the USA: a systematic review and implications for equity amidst COVID-19.  Published online August 13, 2020.  J Racial Ethn Health Disparities. doi:10.1007/s40615-020-00840-5PubMedGoogle Scholar
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American Cancer Society.  Cancer Facts & Figures 2019. American Cancer Society; 2019.
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Mehrotra  A, Chernew  M, Linetsky  M, Hatch  H, Cutler  D. The impact of the COVID-19 pandemic on outpatient visits: a rebound emerges. The Commonwealth Fund. Published May 19, 2020. Accessed October 30, 2020. https://www.commonwealthfund.org/publications/2020/apr/impact-covid-19-outpatient-visits
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DuBois  SA, DuBois  RN.  COVID-19 threatens to increase cancer mortality: here is what we can—and must—do.   The Cancer Letter. 2020;46(35):4-6.Google Scholar
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Wise  J.  Covid-19: cancer mortality could rise at least 20% because of pandemic, study finds.   BMJ. 2020;369:m1735. doi:10.1136/bmj.m1735 PubMedGoogle ScholarCrossref
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