Register for the 21st Annual Spring Cancer Policy Roundtable

Opening Remarks – Shelley Fuld Nasso, MPP
CEO, National Coalition for Cancer Survivorship

Patient Keynote – Julia Maués
Co-Founder, GRASP (Guiding Researchers and Advocates to Scientific Partnerships)

Experimentation in Cancer Care: Inspired (or Forced) by the Pandemic?

12:15 p.m. ET – 1:15 p.m. ET

One of the immediate health care responses to the pandemic was providing telehealth services. Providers embraced the possibility of providing certain services by telehealth, patients welcomed the potential for virtual services, Congress and regulators granted flexibility by waiving certain telehealth requirements, and payers ensured that a payment stream would be available. Experimentation with telehealth was not the only health care delivery response to the pandemic.

Although these health care delivery changes were born of necessity, some believe that several of them – including but not limited to telehealth – should be retained after the pandemic. A concern that has arisen in connection with all of these reforms and experiments is whether the reforms can help address cancer care disparities or instead whether they may worsen disparities.

Session Background Reading

Has the Pandemic Created an Opportunity for Innovation for Quality Cancer Care?

• In a Nature Cancer article early in the pandemic, Mike Richards and colleagues detailed the impact of coronavirus on cancer care and research (including clinical trials) and outlined the steps that health care systems can take to minimize the long term effects.
• In a Viewpoint piece in the Journal of the American Medical Association (JAMA) published in April 2020, Drs. Schrag, Hershman, and Basch described the impact of the pandemic on cancer care and also suggested that the pandemic might create opportunities for lasting cancer care reform.They wrote:
  

  Many patients with cancer are concerned that their needs will be overlooked or marginalized during the COVID-19 crisis. Attending to these legitimate concerns has become, and should be, a focus. Balancing the value of cancer treatments with competing risks during a time of declining resources will increasingly present ethical and logistical challenges to clinical standards and humanism. Because most hospitals and outpatient infusion centers now prohibit visitors from accompanying patients, there is intense attention on clarifying advance directives, health care proxies, and end-of-life care preferences. Oncologists and patients must prioritize these conversations. However, the essential empathy of oncology practice will continue to transcend the new physical barriers presented by masks and telehealth.

  In the space of a month, approaches and accepted norms of cancer care delivery have been transformed of necessity. Most of these changes would not have occurred without the pandemic. Although the immediate priority is to save lives, in the aftermath and recovery phase, evaluating the effects of COVID-19 on cancer mortality will be a priority. Planning for resuming cancer treatment and screening to mitigate harms is already underway. It is also likely that some changes provoked by the crisis will permanently transform how to treat cancer, in some cases perhaps for the benefit of both patients and their physicians.

• In a more recent editorial in the Journal of the American Medical Association, Melinda Buntin discusses the potential for health care reform during the pandemic.  Her opinion piece, not focused on cancer only, is downloadable here.

Mental Health and Cancer Survivors

1:15 p.m. ET – 2:30 p.m. ET

Cancer survivors — including those in active treatment, those with metastatic disease, and those in long-term survivorship — report significant mental health challenges, including depression and anxiety. They also report that the cancer care system is not always responsive to their mental health needs, or that there is poor coordination of care and communication among providers even if they receive quality mental health care services. The pandemic has exacerbated mental health issues for some, and the isolation of the pandemic has posed a challenge for all cancer survivors.

Session Background Reading

Cancer Patients, COVID-19, and Mental Health Issues

• Islam and colleagues reported in the Journal of Oncology Practice about the mental health problems of cancer survivors during the pandemic. The article is an analysis of the COVID Impact Survey.This is the Discussion section of the article; the article can be read in full online:
  
  

  Our study demonstrates several important findings concerning the psychological impacts of the COVID-19 pandemic among cancer survivors. Cancer survivors were more likely to report mental health symptoms, such as anxiety and depressive symptoms, compared with adults without a history of a cancer diagnosis. Additionally, certain demographic groups of cancer survivors were more likely to report mental health symptoms including younger adults, women, and cancer survivors without a high school degree. Cancer survivors with limited social interaction were also more likely to report mental health symptoms. Finally, we found that NH-Black cancer survivors may be less likely to report mental health symptoms compared with NH-White survivors. These findings may have implications for cancer care as poor mental health symptoms among cancer survivors may lead to barriers to successful treatment adherence and lower survival.

  Although there are limited empirical studies that have compared the mental health impacts of COVID-19 among cancer survivors with the general population, prior studies have documented that cancer survivors have unique emotional needs related to anxiety and depression because of fear of recurrences as well as family and interpersonal strain. For example, a cross-sectional survey of patients with cancer in China observed a high prevalence of mental health problems, including depression, anxiety, post-traumatic stress disorder, and hostility during the COVID-19 pandemic. In the United States, a study using a nationally representative sample of adults showed a higher prevalence of anxiety and depressive symptoms during the COVID-19 pandemic, due in part to social isolation and economic hardship. Our study also suggests an important role of social support among cancer survivors during the COVID-19 pandemic.

  We observed that cancer survivors were more likely to volunteer before the COVID-19 pandemic and also were more likely to speak with their neighbors than other adults both before and after the start of the COVID-19 pandemic, indicating they may have stronger social networks. Although studies examining social network patterns during the COVID-19 pandemic among adults with and without cancer are sparse, prior studies have documented increased likelihood of participation among online social support groups and health-related Internet use among cancer survivors compared with those without a cancer history. Increased anxiety, depression, loneliness, and hopelessness among cancer survivors is of major concern because of the potential impacts on quality of life and adherence to cancer survivorship recommendations, including required continuing treatment or wellness recommendations such as exercise and eating healthy.

  Recent work demonstrates that cancer survivors are at higher risk of suicide in comparison with the general population, further underscoring the significance of evaluating mental health symptoms during the COVID-19 pandemic. Social isolation and deteriorated mental health symptoms during the COVID-19 pandemic can be an additional suicide risk during these unprecedented times. Providers should prioritize evaluating mental health symptoms among cancer survivors during their patient-provider interactions; however, recent data demonstrate that cancer survivors are canceling their doctor’s appointments during the COVID-19 pandemic, which may reduce opportunities to interact with patients (15). To address the needs of cancer survivors, many cancer survivorship programs in the United States have converted to telehealth and certain programs have seen success particularly when insurance reimbursement was extended to cover group behavioral telehealth interventions in response to the needs of patients during COVID-19. However, although advances in telehealth offer potential for accessible psychosocial care, significant barriers exist to equitable ease of use and access to the Internet and general technology. Alternative and creative programs, such as group visits, to scale up mental health treatment, are needed to ensure equitable access to care and address the needs of cancer survivors.

  A notable strength of our analysis is we used nationally representative survey data and therefore obtained a representative sample of cancer survivors in the United States. However, our results should be interpreted with several limitations in mind. We relied on self-report of symptoms reported in the 7 days before survey administration. Chronic conditions, including a prior cancer diagnosis, were based on self-report, leading to the potential for measurement error in our definition of a cancer survivor. Although more reliable, data on psychological distress measured using validated scales, such as the General Anxiety Disorder–7 (GAD-7), were not available. We were unable to measure and account for important cancer-related variables such as site, stage, or type of treatment (surgery, chemo, or radiation). We were unable to assess if the respondent was currently undergoing cancer treatment, and if so, how long they have been undergoing treatment or time since treatment. Importantly, data regarding the cancer survivor’s mental health symptoms before COVID-19 were unavailable, and therefore we are unable to conclude if the mental health symptoms are COVID-19–related or because of another cause. We conducted sensitivity analyses to address this concern; however, future research using existing longitudinal cohorts to compare mental health symptoms among cancer survivors before and after COVID-19 pandemic is needed.

  In conclusion, we demonstrated that cancer survivors are reporting mental health symptoms during the COVID-19 pandemic. Providers should prioritize evaluating the mental health symptoms of cancer survivors and use established validated scales to diagnose clinical depression or anxiety to ensure survivors are engaging in the survivorship care they need. Optimizing equitable access to telehealth opportunities for engagement of survivorship care should be prioritized. Future qualitative research into experiences of cancer survivors during the COVID-19 pandemic to elucidate their experience and potential mental health impact should be conducted. As Internet-based interventions to promote social support among cancer survivors have been found to have a positive impact on psychological well-being and quality-of-life outcomes, future studies should engage cancer survivors through e-Health tools during times of social isolation and quarantine during the COVID-19 pandemic.

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• In an online question and answer document, Dr. Scott Irwin of the Patient and Family Support Program at Cedar-Sinai Cancer, addressed the mental health issues that cancer survivors have faced during the coronavirus pandemic.  The document includes links to resources of use to cancer survivors during the pandemic.

Keynote Address: COVID, Cancer Care, and Cancer Research
2:30 p.m. ET – 3:15 p.m. ET

Norman E. “Ned” Sharpless, MD
Director, National Cancer Institute

Early in the pandemic, Dr. Sharpless warned about the devastating effects of the pandemic on cancer care and research.  He urged action to address the interruptions in care and research, and he led by constructive example, providing supplemental funding to support researchers losing private sector funding.  He has also identified research opportunities “created” by the pandemic and encouraged investigation of these intriguing pandemic-related questions. Dr. Sharpless will share his perspective on coronavirus and cancer, how the National Cancer Institute (NCI) is coping through the pandemic, and pandemic-related initiatives that should continue after the pandemic.

Dr. Sharpless has served as the director of the National Cancer Institute (NCI) since October 17, 2017. Prior to his appointment, Dr. Sharpless served as the director of the Lineberger Comprehensive Cancer Center at the University of North Carolina (UNC), a position he held since 2014.

Session Background Reading

The Impact of the Coronavirus Pandemic on Cancer Research and Care

• Early in the coronavirus pandemic, National Cancer Institute (NCI) Director Norman E. Sharpless offered observations and concerns about COVID-19 and cancer in an opinion piece in Science magazine. Dr. Sharpless warned against continued delays in cancer diagnosis and care, noting the potential that the coronavirus crisis could cause additional public health crises.
• In a lengthy interview with the ASCO Post in September 2020, Dr. Sharpless offered details about the impact of the pandemic on cancer patients and the work of NCI to understand how COVID-19 is affecting cancer patients. He described the work of NCI:
  

  We are supporting a few cancer and COVID-19 registries, including the COVID-19 and Cancer Consortium Registry (CCC19; https://ccc19.org). We have also opened our own clinical trial, the NCI COVID-19 in Cancer Patients Study (NCCAPS; https://clinicaltrials.gov/ct2/show/NCT04387656) to collect blood samples, medical information, and images from patients with cancer diagnosed with COVID-19. The study will allow us to analyze the severity of the coronavirus in these patients and the effects of the virus on cancer therapy and clinical outcomes. It will also give us the ability to perform biomarker studies to understand the prevalence of cytokine abnormalities, as well as perform germline sequencing to define genetic polymorphisms associated with severe COVID-19 disease and mortality.

  So far, the registry efforts have taught us that some patients with cancer who contract COVID-19 seem to have a worse prognosis than those without cancer. For example, patients with lung cancer and those with hematologic malignancies seem to have worse outcomes, which is not surprising. We are also seeing that these patients are likely to gain access to some of the experimental medicines for COVID-19, including remdesivir, dexamethasone, and tocilizumab for COVID-19–induced cytokine-release syndrome. However, there is more to learn.

  The most interesting question to me about COVID-19 clinical outcomes is why there is such a strong age disparity in outcome. I can’t think of another viral disease in which the illness is so much more lethal in an 80-year-old patient than a 20-year-old patient. There is a notion that certain types of cancer therapy, such as cytotoxic therapies like platinum-based chemotherapy and radiation therapy, cause a form of physiologic or accelerated aging, putting older patients with cancer at greater risk of death from COVID-19.

  This is an interesting scientific question. The NCI and the National Institute on Aging have held joint meetings on the topic to see whether this notion is true and whether anything can be done to circumvent worse outcomes in these older patients. We have learned a lot about the clinical outcomes of this virus since March, but there are more key questions to address regarding clinical approaches to improve outcomes.

• In December 2020, Dr. Sharpless looked forward to a research rebound in 2021 and described the efforts of NCI to address pandemic-related disruptions in research.