ESMO 2020 | CCOS study: disparities in cancer during the COVID-19 pandemic

With our colleagues in Boston, we were very hard hit by the COVID 19 pandemic, especially starting in March and through the month of April. And as oncologists, we worked very hard to try to reduce the risk that our patients would get COVID knowing that they were particularly susceptible. And among the many interventions that we installed included using telehealth, trying to limit unnecessary visits, trying to change regimens so they would be less myelosuppressive and so on. But we really didn’t have any data prospectively on how our delivery of cancer care was changing due to the pandemic.

So a lot of other researchers had specifically looked at cancer patients who developed COVID-19, but we wanted to look at a different question, which was how was the pandemic impacting the delivery of cancer care? So we designed a large cohort study with over 2000 patients at Mount Sinai and at Dana-Farber. And we looked at Mount Sinai, at all the patients who had been seen in our outpatient oncology clinics with solid malignancies and hematologic malignancies. During the first week of March. At Dana-Farber, we looked at patients with head and neck cancer, lung cancer, and genital urinary cancers because they’re very large centers. So we needed to look at a smaller group.

And basically we called that the index week. And then we looked at how those patients had been treated for their cancer the three months prior. So basically December through the beginning of March and then prospectively from March to June. And we wanted to compare the two periods, looking at how their care was altered. Primarily looking at the kinds of visits they had, whether they were total visits, in-person visits, telehealth visits, treatment delays, and whether or not patients actually developed COVID-19. And we actually had some expected and some unexpected findings.

So as we expected overall visits, overall trended down, as we were trying to limit patient exposure to the healthcare system. In-person visits trended down from the pandemic period from March to June, compared to the baseline period from December to March. And telehealth visits overall, there was a trend toward increased telehealth visits. So those were all things we expected to find. We also collected information about patient self-described, race and ethnicity. And unfortunately I could describe these findings as unexpected, but given some of the other findings showing that patients from minority backgrounds are more susceptible to the virus and to poor outcomes from the virus. Unfortunately, we found that our black and Hispanic patients were less likely to have increased telehealth visits compared to white patients. We found that they were more likely to develop COVID-19.

We also found that Hispanic patients were more likely than white patients to have delays in their cancer care. This study really demonstrated that unfortunately, cancer patients who are from non-white backgrounds really have a compounded risk for disrupted cancer care during the pandemic. We know that patients with cancer are at higher risk from COVID-19. We know that patients from minority backgrounds are at higher risk. And what we showed here was that cancer patients from minority, ethnic, and racial backgrounds are at higher risk from having disrupted cancer care during the pandemic.

So while a lot of the reasons for these disparities were not explored in this study, this is an observational cohort study. I think we can certainly think about the many reasons why we might’ve seen these disparities thinking about issues like language barriers, healthcare literacy, theory, longstanding issues of socioeconomic inequities, racial inequities that are not easy to just solve. But I think if we focus for example, on telehealth, which is one very concrete way that we can intervene. We know that telehealth is a great way to minimize patient exposure to the healthcare system and to healthcare facilities. But for whatever reason, it was not utilized as much in our minority populations.

So I think we really need to understand why that’s happening. I think I could point to a few different reasons that I’ve experienced in clinical practice. So some patients don’t have reliable internet. Some patients don’t have smartphones. A lot of patients don’t have the technology they need to connect. And honestly, using our technology is not super straightforward. There’s a phone call to make sure they’re available and then they have to connect using their phone through an EMR app. So if you’re not really technologically savvy, if there’s a language barrier that may be difficult because how do you introduce an interpreter? For example, are you going to use an extra phone to have an interpreter also on the line?

So I think we need to make really concerted efforts to make sure that our patients from non-white backgrounds are able to fully participate in telehealth. I think potentially using patient navigators to actually train our patients before their first telehealth appointment could be very beneficial, and to make sure that they have all of the equipment they need. But I do think further prospective research into that specific question is really warranted.