Those of us remaining have assumed their clinical responsibilities, sharing the enlarged burden of patient care both in and out of the hospital. We are facing serious, unresolved questions about how to practice oncology in the covid-19 world.
First, what is our threshold for having patients come to the clinic to receive treatment if it means possibly exposing them to covid-19? Some scenarios have easy solutions. If they require lifesaving therapy, then the benefit of treating them outweighs the risk. Similarly, if patients are scheduled for routine follow-up visits, then these appointments can be delayed with little cost.
But what about the ever-increasing gray areas of oncology? What if patients are scheduled for a drug that increases their chance of long-term survival but only modestly? Is it worth coming to the clinic and potentially exposing yourself to covid-19 for a treatment that increases your chance of survival from 85 percent to 90 percent? What about from 40 percent to 55 percent? What if that patient is 75 years old? What about 45 years old?
Second, how do we take care of those newly diagnosed with cancer? The American Cancer Society estimates there will be 120,000 new cancer diagnoses in New York state in 2020, many of which are curable. A new diagnosis often involves a multidisciplinary team, including interventional radiologists, surgeons, medical oncologists and radiation oncologists working together to coordinate the timing and sequence of diagnostic tests and treatments. Curable, early-stage breast cancer, for example, can involve a biopsy, radiation, chemotherapy and surgery. But nonemergent surgeries and procedures are on hold across the city as operating rooms are being rapidly repurposed for covid-19 treatment. How long can we delay these procedures before we risk a curable cancer becoming incurable?
There is, of course, no clear-cut answer to any of these questions, and New York is not unique. Almost hourly, there are newly published recommendations from institutions and professional organizations putting forth general frameworks for how to approach taking care of cancer patients during this crisis. But the answer is the same: There is no right answer. Each case should be evaluated individually.
We have witnessed unimaginable creativity from our colleagues fighting on the front lines who have run straight through obstacles to convert an entire hospital into an ICU in a matter of days. Inspired by them, my colleagues and I are grasping for whatever technological advantage we can get our hands on to continue to care for cancer patients safely. We now rely heavily on video visits with our patients. Instead of having them come in for bloodwork, we arrange for their blood to be drawn at local labs. For those patients in the gray zone, we work closely with our dedicated surgical and radiation-oncology colleagues to prioritize treatments.
And how have our patients responded? They are asking how we are doing. They have asked us how they can help us. I have had multiple patients and their family members ask how they can volunteer their efforts to help our hospital.
Perhaps it is not unexpected that cancer patients have remained calm amid the pandemic. The lack of control that we all feel from covid-19 — the sense of powerlessness — is not an unusual feeling for them. When patients are diagnosed with cancer, they experience the same dizzying uncertainty and confusion that upend their entire world. They are accustomed to living scan to scan, treatment to treatment, day to day. Uncertainty is their normalcy.
Their grace in the face of this chaos has been stirring. Our mission to find answers for them continues, strengthened by their equanimity.
A crisis can break bonds, but it can also reinforce them. For all of the hell covid-19 has wrought, it has awakened a deep solidarity within medicine. I have never felt closer to my patients than I do now. And I have never felt prouder to work alongside the fearless and selfless nurses, doctors and staff who are throwing their energies into holding the front lines against this wild force.
Inscribed along the lobby wall of our pediatric floor, which has now been converted into a covid-19 ward, is the famous ending to Percy Shelley's poignant “Ode to the West Wind.” The poet, bearing witness to an agent of destruction, looks ahead and envisions an end to the darkness.
“O Wind, If Winter comes, can Spring be far behind?”