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Cancer Care Chronicles
March 18, 2021

Last Christmas—Counseling Patients in the Era of COVID-19

Author Affiliations
  • 1Divisions of Oncology and Hematology, University of North Carolina School of Medicine, Chapel Hill
  • 2Geriatric Oncology Program, University of North Carolina School of Medicine, Chapel Hill
JAMA Oncol. 2021;7(5):681-682. doi:10.1001/jamaoncol.2021.0125

When I began my oncology fellowship, I anticipated leading difficult conversations with patients. I welcomed the opportunity and challenge of engaging with people during some of the most difficult experiences of their lives. I foresaw discussing pathogenesis and prognosis, treatment and toxic effects, and hope and healing. I felt that my earlier training experiences had left me well equipped to convey this information and these ideas clearly, in a manner that would facilitate understanding and aid decision-making for patients and their families.

I did not anticipate the frequency with which I would instead discuss travel plans, but the coronavirus disease 2019 (COVID-19) pandemic has spawned a series of such conversations, with questions about risks and appeals for advice. The first of these exchanges occurred at night during the first wave of the pandemic. The hospital operator paged me, the on-call fellow, regarding an outpatient who wanted to talk about my thoughts on the safety of visiting grandparents out of state. The question seemed straightforward, and I advised against traveling. The short-term risks were too high, and it might instead make sense to travel when the pandemic had abated.

In the weeks that followed, I had several similar conversations, either by telephone or in person, with patients about their concerns regarding travel in the COVID-19 era. In each case, in addition to recommending handwashing, mask wearing, and social distancing, I advised patients to avoid travel whenever possible. These patients generally expressed appreciation for clear guidance in the face of mixed messages from various governmental sources and national media. Almost everyone was anxious. However, with summer came falling case numbers, and these questions became less frequent.

The Winter Surge

When winter holidays approached and COVID-19 cases started rising across the country, these conversations began again. By and large, the anxiety was gone or had at least receded behind other emotions. In its place, I encountered the distress of new grandparents who had never seen their grandchild because of their concerns regarding infection risk. They were now asking about travel to see family this winter.

I share the frustration of a patient who unexpectedly retired following a pandemic-related job loss. The patient began planning a vacation as case numbers declined over the summer but was confronted by a diagnosis of lymphoma. This patient’s questions about the safety of travel in the setting of cancer and chemotherapy echo what numerous other patients and clinicians have shared regarding the unfairness of confronting month after month of social distancing when their life expectancy is being measured in months rather than years.1

Other patients with poor prognoses, who have had their time with family cut short, share their anger. Several have mused that they could be facing their “last Christmas” and that continuing to stay distanced from family through the holidays is not acceptable. Family members of a patient with metastatic esophageal cancer shared their sorrow when their loved one did not live until what would have been their last Christmas together. Instead, the pandemic complicated arrangements for the funeral, with questions about if and how travel should be coordinated.

Official Guidance

Various news outlets have covered recommendations from the Centers for Disease Control and Prevention (CDC) regarding planning for holidays—generally summarized as, “don’t travel.”2,3 Actually, the published CDC recommendations are more nuanced, stratifying various activities by degree of associated risk.4 However, recommendations for patients with cancer are more direct. Cancer is first among the CDC list of certain medical conditions that confer increased risk of severe COVID-19–related illness; these individuals are directly advised to avoid gathering with anyone outside of their immediate household.

Individualized Counseling

As the pandemic has worn on, I have found myself unable to continue making such a blanket recommendation to patients considering travel. I have been unable to tell people with an unfavorable prognosis, those who may not live through the pandemic regardless of whether they contract COVID-19, that they should avoid all contact with their families. Instead, I have found myself talking about travel and contact with loved ones much like I talk about chemotherapy—that is, in terms of potential benefits, possible adverse effects, and mitigation of risk. We discuss other measures, such as the use of masks in public and in others’ homes, handwashing, distancing as able, and being outdoors when possible.

The recent emergency authorization of effective vaccines offers the hope that the need for precautions will soon end, although not as soon as we would like. I make clear that the safest course is to minimize contact, but each individual must ultimately make their own decision. This analogy of travel-as-systemic-therapy obviously breaks down if examined too closely, given that chemotherapy rarely poses a risk to family members, whereas COVID-19 is a risk to both patients and those around them. Therefore, I encourage patients to discuss the potential risks with their families, and patients have reported back to me on discussions that have come down on either side of the debate on traveling.

Now, looking back on the past several months and looking forward to the months ahead, I have come to the conclusion that these conversations on travel, despite the unexpected content, are essentially the same conversations I had envisioned before starting my fellowship. Blanket advisories are unable to accommodate the nuances of the individual experience and all specific medical decisions are ultimately personal. My role remains to convey medical information and ideas clearly, in a manner that facilitates understanding and aids in decision-making, but the decision-making locus remains with patients and their families.

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Article Information

Corresponding Author: Christopher E. Jensen, MD, Divisions of Oncology and Hematology and Geriatric Oncology Program, University of North Carolina School of Medicine, Physicians Office Building, CB# 7305, 3rd Floor, 170 Manning Dr, Chapel Hill, NC 27599 (christopher.jensen@unchealth.unc.edu).

Published Online: March 18, 2021. doi:10.1001/jamaoncol.2021.0125

Conflict of Interest Disclosures: Dr Jensen reports a grant from the National Institutes of Health (National Research Service Award T32-CA233419) outside the submitted work.

Additional Contributions: We thank the patients and their families for granting permission to publish this information.

References
1.
Sanoff  HK.  Managing grief, loss, and connection in oncology—what COVID-19 has taken.   JAMA Oncol. 2020;6(11):1700-1701. doi:10.1001/jamaoncol.2020.2839PubMedGoogle ScholarCrossref
2.
Dwyer  C. Don’t travel for Thanksgiving, CDC warns. National Public Radio. November 19, 2020. Accessed November 22, 2020. https://www.npr.org/sections/coronavirus-live-updates/2020/11/19/936715870/dont-travel-for-thanksgiving-cdc-warns
3.
Moniuszko  SM. CDC recommends that Americans don’t travel for Thanksgiving. USA Today. November 19, 2020. Accessed November 22, 2020. https://www.usatoday.com/story/travel/news/2020/11/19/holiday-travel-cdc-recommends-americans-dont-travel-thanksgiving/3779090001/
4.
Centers for Disease Control and Prevention. Holiday celebrations and small gatherings. November 19, 2020. Accessed November 22, 2020. https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/holidays.html
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