(UroToday.com) The 2020 American Society of Clinical Oncologists (ASCO) virtual education program featured a roundtable discussion with several health policy leaders regarding ethical issues that have been raised in oncology during the COVID-19 pandemic. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
The chair of the program, Dr. Angela Bradbury started this panel discussion by presenting a case. The patient is a 67-year-old man who had progressive dysphagia, which worsened during the COVID-19 stay at home orders. He then contacted his primary care physician, but their office was closed, so he drove to a local emergency room but was reluctant to go in after seeing lines of patients and tents outside. His symptoms subsequently worsened, and he finally reached his primary care doctor who referred him for an esophagogastroduodenoscopy (EGD), but there were subsequent delays in receiving the procedure. After weeks of progressive symptoms and weight loss, his wife took him to the emergency room, where imaging revealed a locally-advanced distal esophageal mass. He was then transferred to a tertiary center that has advanced interventional endoscopy services and was diagnosed with a large, near-obstructing mass of the lower third of the esophagus, with a biopsy confirming esophageal adenocarcinoma. Endoscopic ultrasound was then performed, staging the cancer as cT3N1. The surgical oncologist recommended that the patient undergo a staging laparoscopy and J-tube placement, but OR utilization was currently limited to emergent procedures and the procedure was not performed. Instead, an interventional endoscopist placed an esophageal stent under sedation. His case was then presented at a multidisciplinary tumor board that agreed with a plan to proceed with neoadjuvant chemoradiation, however, during the treatment, the patient learned that he had been in close contact with a COVID-19 individual. The day before his treatment, he was called by the clinic to confirm that he does not have any COVID-related symptoms or recent exposures that may put the staff at risk. However, he was concerned that if he mentions his potential exposure that he will not be allowed to come in for his treatment. The patient was also aware from the support group he recently joined that patients at another center have not had any trouble getting appointments and surgery times. He had already been told that the operating rooms at his hospital have re-opened, but given the forecast for an expected surge, they may be closed again when it comes time for his planned definitive esophagectomy.
Unfortunately, regardless of specialty, we have all likely faced similar scenarios with oncology patients during the last five months of the COVID-19 pandemic. To discuss perspectives relating to this case, Dr. Bradbury assembled a panel that included the following individuals to discuss various perspectives:
- Jonathan Marron to discuss the policy perspective
- Sabha Ganai to discuss the surgical perspective
- Colleen Gallagher to discuss the clinical ethics perspective
- Kayte Spector-Bagdady to discuss the legal perspective
- Banu Symington to discuss the community perspective
To discuss the surgical perspective of these challenges, Dr. Sagha Ganai started by noting that during the early phase of the pandemic in March 2020, many centers had to halt elective surgery under the guidance of Centers for Medicare & Medicaid Services (CMS) and the American College of Surgeons. However, she notes that there was great variability across different states and jurisdictions emphasizing that many jurisdictions did not enforce a specific elective surgery policy. One could argue that there was outside pressure to keep hospitals and operative practices open in order to keep these entities financially liquid. However, she emphasized that many surgeons did cut back on elective procedures secondary to concerns for safety and conservation of resources. This included conservation of personal protective equipment, anesthesia staffing capacity, ventilator availability, and especially in New York City, many ORs becoming COVID ICUs. Furthermore, there was an inability to test patients for COVID-19 preoperatively, and Dr. Ganai notes that we are still having challenges with preoperative testing in certain areas of the country.
Dr. Ganai highlighted that the international COVIDSurg Collaborative assessed 1,128 patients undergoing surgery between January 1, 2020, to March 31, 2020, of whom 835 (74.0%) had emergency surgery and 280 (24.8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26.1%) of patients, with a 30-day mortality rate of 23.8% (268 of 1,128 patients). Anecdotally, Dr. Ganai also noted that she and her colleagues have seen several additional issues during this time period including odd thromboembolic events, wound issues, and anastomotic leaks, on patients that were otherwise asymptomatic. Risk factors for these issues, included obesity, elderly patients, and being male. Additional concerns during the early phase of the pandemic included the supply chain for sedation medications, staplers, surgical drapes, and surgical gowns. The ability to perform more complex surgery is also complicated by the need for possible ICU space, according to Dr. Ganai. The debate that was often brought up during these early months was whether cancer surgery really is truly elective. Although varying by disease site, many governing bodies provided guidance as to which procedures could be safely delayed, those which should proceed, as well as cases that should favor more prolonged neoadjuvant therapy. The decision to open operating rooms again for elective procedures is also highly variable, depending on local jurisdictions, as well as second-wave surges that we are currently seeing in various parts of the country. Most centers are currently favoring performing routine testing prior to surgery, but this also depends on the ability to perform testing in a reasonable time frame preoperatively (ie. 12-24 hours). According to Dr. Ganai, surgery plays an important role in delivering adequate cancer care, but we have to make it safe, protecting our patients, ourselves, and our colleagues.
Dr. Jonathan Marron notes that the pandemic has provided us an opportunity to reflect on how and why we make the decisions that we make in oncology. A lot of practices have been done for decades “because this is the way we’ve always done it”, versus being backed by objective data. The COVID-19 pandemic has highlighted that we need to make decisions based on facts: for example, is a surgical delay really going to affect a patient long-term?
Professor Kayte Spector noted that scare resource allocation has become an ongoing issue for physicians during the pandemic. There are differences with regards to how physicians may approach an individual patient versus how medicine approaches whole communities. General bioethics focuses on patient autonomy and beneficence, whereas a public health ethics approach focuses on beneficence at the community level, as well as social justice issues (what’s best for the community rather than the patient level). She notes that what has become important during the COVID-19 pandemic is the difference between “medical futility” and “rationing”. Medical futility being at the patient level with regards to whether a particular treatment will benefit the patient, versus rationing of resources to protect the interests of the whole community. This has been common in both the academic literature and public media, for example with the availability of ventilators. To summarize scarce resource allocation Professor Spector highlights that:
- It is important to understand that it makes us uncomfortable to have to emphasize the need of our community when we are used to emphasizing the need of our patient
- Individual doctors shouldn’t be making these decisions, but rather these decisions should be made at the administrative level so that allocation is systemically fair to the community
- There are already so many biases built into the system, it is important that we are not exacerbating them through resource allocation
Over the course of the COVID-19 pandemic we are seeing differing issues and challenges in different communities, whether urban versus more rural settings. Dr. Banu Symington, who practices in rural Wyoming, notes that communities like hers are lacking in many administrative levels, including social works, financial counselors, etc. Furthermore, because of limited clinical staff, if a physician were to test positive for COVID-19, it is likely that an entire cancer center would have to quarantine for 14 days. Additionally, there are challenges, according to Dr. Symington, of rural communities being less likely to take the COVID-19 pandemic seriously.
Dr. Jonathan Marron highlighted that as the pandemic continued, challenges became clear of quickly implementing new policies for our hospitals and our clinics. He notes that as oncologists we are good at treating those patients that are in front of us in our clinic, but not as comfortable with making decisions that benefit society as a whole. Many states and hospitals have subsequently made policies with regard to the allocation of resources. However, one of the questions that arose was whether oncology patients should have the same access to these scarce resources, with some policies giving less access to resources among patients with comorbidities, including cancer. It may be easy to allocate the last ventilator to someone who is expected to survive 20-30 years rather than a cancer patient who is expected to live 2-3 weeks, however, Dr. Marron notes that these decisions are more difficult with subtleties such as making judgments on someone’s quality of life and questionable life expectancy. The oncology community has advocated over the course of the pandemic that having a cancer diagnosis alone should not deter one from receiving resources that are in short supply. Dr. Colleen Gallagher then highlighted that one of the resources we have that we may forget at times is that many institutions have ethicists on staff to help make difficult resource decisions in a fair and ethical manner. An ethicist can help walk through issues at the patient, institution, and community level to assist in making decisions that we are not typically used to making.
Dr. Bradbury notes that in the aforementioned clinical case, the patient had difficulty answering some of the COVID-19 screening questions. Just as clinicians are having challenges during these unprecedented times, patients are also having unique challenges. Dr. Banu Symington emphasized that distrust in the system has led to anxiety for many patients. The fact that masks were not recommended/mandated 3 months ago but now are, has led to distrust in the community towards medical leaders such as Dr. Fauci. Mistrust during cancer treatment also leads to increased anxiety, particularly during delays in treatment and shortages of necessary therapies.
Dr. Colleen Gallagher notes that there are various initiatives to help alleviate the moral distress and anxiety associated with the COVID-19 pandemic. These include virtual platforms to discuss ongoing life in the hospital, fitness initiatives amongst hospital staff, and child-care resources. These initiatives create a culture of trust and appreciation amongst an institution and highlight that the institution cares about the individual employees. At the patient level, events are important for families and patients to have outlets, reaching out to their clinicians and support groups. Many of these initiatives have also been launched virtually. Dr. Marron notes that ASCO has also been central to this work, for example by assembling a task force on physician well-being.2
Dr. Gallagher then discussed how we are going to navigate geographical differences in resources for administering cancer care. We know that coordination and communication are key: this includes utilizing physician networks, particularly at big institutions such as the MD Anderson Cancer Center where she works and sharing best practice guidelines that are crucial during times like this COVID-19 pandemic. By having coordination of care across centers, in addition to transparency, this likely cuts down on “hospital shopping,” according to Dr. Gallagher.
The panelist concluded that it is important to be transparent with the patients and the public in an effort to decrease moral distress. This includes having a framework for policies designed by clinicians as well as ethicists.
Chair: Angela R. Bradbury, The University of Pennsylvania, Philadelphia, PA
Panelist: Colleen M. Gallagher, The University of Texas MD Anderson Cancer Center, Houston, TX
Panelist: Jonathan M Marron, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA
Panelist: Kayte Spector-Bagdady, University of Michigan, Ann Arbor, MI
Panelist: Sabha Ganai, Southern Illinois University School of Medicine Office for Population Science and Policy, Springfield, IL
Panelist: Banu Symington, Sweetwater Regional Cancer Center, Memorial Hospital of Sweetwater County, Rock Springs, WY
Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Augusta, GA, USA, Twitter: @zklaassen_md, at the ASCO20 Virtual Education Program, #ASCO20, August 8-10, 2020.
1. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: An international cohort study. Lancet 2020 Jul 4;396(10243):27-38.
2. Hlubocky FJ, Taylor LP, Marron JM, et al. A Call to Action: Ethics Committee Roundtable Recommendations for Addressing Burnout and Moral Distress in Oncology. JCO Oncol Practice 2020;16(4):191-199.
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