4 Lessons for Late Stage Cancer Care During COVID-19

COVID-19 has had dramatic impacts on all aspects of healthcare, including treatment selection and monitoring of late stage cancers. Last week, I had the pleasure of moderating a workshop on this topic as part of the Association for Molecular Pathology 2020 conference, bringing together four global experts in oncology and pathology:

• Dr. David Huntsman, University of British Columbia and Canexia Health (Canada)
• Dr. William G. Morice II, Mayo Clinic Labs and Mayo Clinic (US)
• Dr. Joerg Kriegsmann, Sonic Germany (Germany)
• Dr. Rosalyn Juergens, McMaster University and The Johns Hopkins Medical Institute (Canada)

As I shared at the outset of the workshop, we’ve seen a massive decrease in cancer screenings and biopsies during the pandemic — up to 80 percent in some regions of the world. 

Here are illustrations of these staggering numbers, first in the US:

 

And in Canada:

 

How can we best address challenges to cancer care during COVID-19, and what does progress look like? 

Here is what the experts had to say. 

 

1. Understand that patients and health systems are struggling.

“We’re no longer seeing patients coming in as a result of incidental findings. We’re seeing the sickest of the sick, the ones who make it in to be seen [in spite of their fear of exposure to COVID-19],” said Dr. Juergens. “Delays because of health system constraints and delays because of patient fear are both issues.”

She later added, “Shipping samples across the [Canada/US] border has also created delays, and we’ve also had shipments of reagents to our lab delayed. That’s just not sustainable.”

Added Dr. Morice, “Mid-sized hospitals lack the necessary resources to scale-up testing services and so rely on large high-throughput labs, which have been overburdened with COVID-19 testing — causing delays in other necessary lab tests like cancer diagnostics. We need to see a hybrid solution where some of this necessary testing is enabled locally to offset the burden on larger labs.” 

 

2. At the same time, COVID-19 has driven some positive changes, including access to telehealth and liquid biopsy. 

“We’ve seen some real disruption,” said Dr. Morice. “We now do more virtual visits daily (at Mayo) than we did in the entire year of 2019. We will see the global landscape of healthcare change as we emerge from this.” 

According to Dr. Huntsman, “Circulating tumor DNA (ctDNA) testing is providing an opportunity to de-risk patients, as well as overcome inequities in access. Treatment decisions can be made without patient exposure. In Canada, the federal government has recognized COVID-19 is changing healthcare forever. They funded an initiative, Project ACTT, to make ctDNA testing available to Canadians during the pandemic.”

Added Dr. Juergens, “We would love to see a day when liquid biopsy is really augmenting what we do, when we can reduce tissue biopsies, when we can follow patients with liquid biopsy for monitoring for minimal residual disease, to determine who needs certain treatments. When we can sort out what’s going on at the molecular level and tailor treatment delivery.” 

 

3. Localized testing is proving to be a promising disruptor to help cancer patients while reducing risks and increasing access. 

“The highly centralized model for labs may have to shift. Hospitals will have to be able to test locally, which will also close disparities in delivery,” said Dr. Morice. “We’re realizing the immediacy of results is really important, and the paradigm is changing for what people will expect. They will expect diagnostic results without having to go into a healthcare center. This is really stretching how diagnostics will be provided and delivered. Many of the disruptive tools (like liquid biopsy and cloud technologies) exist today. The real disruption will be in how these tools are packaged and ingested into healthcare delivery, like localized testing.” 

 

4. Reimbursement will be key as cost-pressures continue to squeeze hospitals.

According to Dr. Kriegsmann, “In Germany, if you want to provide liquid biopsy to public patients, this is a challenge given reimbursement. But we’re moving towards it. As a pathologist, it is easy to do if you can do it locally, but not so much if you have to ship samples across the country.” 

In Canada, Dr. Juergens said they’ve seen success with liquid biopsy, but reimbursement is also an issue there. “We’ve been able to get information about the patient back faster, and make clinical decisions more quickly. We’ve had to be crafty, though. We only have access [to liquid biopsy] via clinical trials or if patients can pay [out of pocket].”

Dr. Morice added, “The pandemic has shown us that we really need a sea change in policies. At the same time, economic stressors are being exacerbated by COVID. There will be lots of cost pressures. We’re going to need testing solutions that are more deployable and require less overhead support.”

The panelists also discussed the impact on clinical trials and how COVID-19 is beginning to break down traditional silos. At the end of this pandemic, said Dr. Huntsman, “I think we’ll see a huge change in global cancer care.”

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