In oncology, we are reminded daily that covid-19 is far more than just a disease of the lungs. Apart from being a perpetual risk to highly vulnerable cancer patients, the coronavirus has overrun health-care systems and thus frustrated efforts to diagnose and treat cancer.
One patient's story
Ms. H’s colon cancer was progressing at a breakneck pace. (I’m using only her initial to protect her privacy.) Although it had been only a few weeks since the diagnosis was confirmed, she was now dependent on supplemental oxygen to breathe and required wheelchair assistance during my clinic appointments with her.
After a discussion with Ms. H and her family, we decided to try a cycle of low-intensity chemotherapy as an attempt to palliate her increasingly severe symptoms. Given her frailty and advanced age of 76, this was a decision laced with both hope and risk.
But just a couple of days after the toxic drugs were infused, their adverse effects began to manifest. Ms. H’s daughter called to report her mother’s significant fatigue and reduced food intake. Bloodwork that was subsequently ordered revealed dangerous electrolyte levels and significant kidney dysfunction. To address these physiological abnormalities urgently and thoroughly, Ms. H would need to be admitted to the hospital.
Before the recent decline in coronavirus cases, much of America found itself mired in the second wave of the pandemic. More than 100,000 Americans were consistently hospitalized with the virus. And here in Chicago, many hospitals had admitted more patients than at any time during the surge last spring.
Anticipating possible delays related to covid-19 in the hospital’s emergency room, I called ahead to brief a doctor there about Ms. H’s acute medical condition and imminent arrival. This was the usual procedure to make the patient handoff seamless and efficient. Yet despite the communication, she remained in the waiting room for a few hours in pain and with an almost depleted oxygen tank before being seen by a nurse.
In an ER that was buffeted by ballooning severe covid-19 cases and a shortage of medical staff, Ms. H was given a makeshift bed in the hallway and left largely unattended. She received perfunctory care that included IV fluids, a belated dose of pain medication and a promise to be placed in the growing queue of patients waiting for a hospital room. Many hours then passed in limbo and without any plan from the doctor for further tests or treatment.
Tired and uncomfortable, Ms. H finally asked to be sent home. For at least this one night, she wanted some relief from the furor of this ER that was fully strained by covid-19. The already delayed needs of her Stage 4 cancer-riddled body and its attendant complications would now wait until the morning.
The following day, Ms. H’s daughter called 911 after she found her mother confused and unable to get out of bed. She was immediately admitted to another hospital near her home for a much delayed evaluation.
With her initial experience, Ms. H joined a few of my other patients with advanced cancers who could not obtain timely medical care at hospitals ravaged by the recent covid-19 surge. While I have been able to improvise care for some of them with IV fluids, bloodwork, electrolyte repletions and blood transfusions in the outpatient setting, Ms. H’s acuity was beyond the limits of my clinic.
Myriad pandemic problems
The casualties of the pandemic number far greater than just those infected by the virus. An absence or loss of health insurance coupled with fears of contracting covid-19 from visiting hospitals and clinics has resulted in postponed or forgone non-covid-19 medical care. Immunizations for children have dangerously ebbed, and far fewer patients with heart attacks and strokes are coming to hospitals than expected. Recent data published in JAMA showed that 33 percent of “excess deaths” — the number of deaths above anticipated baseline levels — during the pandemic period could not be ascribed to covid-19.
Complications related to cancer and to its treatment often require hospitalization. And many times, the surgery, radiation and medicines needed to achieve remission or palliate cancer can be more punishing than the immediate effects of the disease itself.
A 2016 study looked at the hospitalization rates in patients 66 or older who had metastatic cancers of the lung, breast, colon, prostate and other sites. Of those receiving chemotherapy, a treatment used commonly in advanced cancers, 92 percent were hospitalized at least once for issues such as infection, dehydration, malnutrition, gastrointestinal symptoms, low blood cell counts and blood clots.
The need for hospital care, which is often unplanned, arises soon after a cancer is diagnosed.
A 2019 study found that almost 60 percent of patients with various stages of cancer visited the ER during the first six months after diagnosis for complaints such as pain, dehydration, fever, nausea, vomiting or shortness of breath. Almost all were later admitted to the hospital due to the severity of their symptoms.
With cancer, hospitalization can escalate quickly to a need for the intensive care unit (ICU) due to organ failure or septic shock. Patients with blood cancers like leukemia and lymphoma and solid tumors such as lung cancer are at a heightened risk for life-threatening complications that may necessitate ICU admission. About 40 percent of those who receive a stem cell transplant become gravely ill and require elevated care in the ICU.
And since the highest ICU mortality rates are seen in oncologic patients whose lungs fail them, any shortage of ventilators is deadly.
A compromised system
This all compounds the considerable pandemic challenges already being faced by oncologists and cancer patients. The upheaval not only has made oncologists anxious and depressed about their inability to provide appropriate cancer care for their patients but also has left them concerned that care for non-covid-19 illnesses will be compromised.
Preventive cancer screenings and new diagnoses are down significantly. Delays in surgery, radiation and chemotherapy have been particularly notable in light of a recent British Medical Journal study of seven common cancers showing that even a four-week postponement can affect mortality. And millions of immunocompromised cancer patients live daily with the knowledge that they are at increased risk for severe covid-19.
Coronavirus vaccines promise to radically alter this country’s pandemic narrative as soon as the fall. But until then, any further surges in America’s hospitals will hamstring their ability to care for the sickest cancer patients. This all may be exacerbated by the looming threat from coronavirus variants that may be more transmissible, deadlier or resistant to vaccines.
In a pandemic that has already impaired our ability to diagnose, protect and treat those with cancer, this would be unconscionable.