By Robert Levy
When Dana-Farber began mapping its strategy for the COVID-19 outbreak early this year, questions about whether the crisis would prompt lasting changes in patient care were largely academic. The challenge of providing quality cancer care and conducting clinical research amid a global pandemic required an unswerving focus on the here and now.
Research technician Daan Overwijn is on a team of Dana-Farber scientists seeking to learn more about COVID-19 antibodies.
But as often happens, changes made in the crucible of a crisis have proved surprisingly durable. Just as surgical techniques invented for the battlefield have entered routine practice, some of the policies prompted by the pandemic have been incorporated into standard care procedures at Dana-Farber generally and the Susan F. Smith Center for Women's Cancers in particular.
As the coronavirus that causes COVID-19 bore down on New England in the first months of 2020, the Institute adopted a range of measures to reduce the risk of transmission and keep patients and staff safe. Mask-wearing became mandatory. Patients were pre-screened for COVID-19 symptoms and asked if they'd come in contact with anyone with the disease. Procedures for isolating and caring for patients who might have been previously exposed to the virus were put in place. Waiting areas held fewer seats, and chairs in exam rooms were placed further apart. Telemedicine visits between patients and clinicians soared. Behind the scenes, staff worked overtime to procure an adequate supply of personal protective equipment (PPE), and most non-clinical staff began working from home to reduce the opportunities for disease spread.
Amidst all this, what didn't change was the quality of care patients received, clinicians say. In fact, it was largely because of these changes and because patients felt safe in continuing to receive care at Dana-Farber that treatment remained on track.
"I know my patients appreciated the arrangements Dana-Farber had made, the attention to detail and to safety," says Panos Konstantinopoulos, MD, PhD, director of translational research, Gynecologic Oncology. "Overwhelmingly, I heard from patients that they felt secure, they felt cared for, and they understood why these steps had been taken."
Telemedicine on Trial
One of the most wide-ranging changes, and one likely to remain over the long run, is the shift toward telemedicine, or virtual visits, hosted by online services such as Zoom. From a pre-COVID starting point, in which virtual meetings between Dana-Farber clinicians and patients were a rarity, virtual visits during the early months of the pandemic increased dramatically, accounting for more than half of all visits between Susan F. Smith Center clinicians and patients at one point. The rationale for this change was obvious — online meetings would reduce the number of patients and clinicians physically at Dana-Farber, deterring the spread of the coronavirus — but the virtues of virtual visits became more apparent as their use grew.
In the wake of the COVID-19 pandemic, Dana-Farber converted more than 50% of its outpatient appointments to telehealth, or virtual visits.
"If applied thoughtfully, videoconferencing could account for 20-25% of patient visits at Dana-Farber long-term," says Eric P. Winer, MD, chief of the Institute's Division of Breast Oncology. "Not only is it more convenient for some patients, particularly if they live far from the Institute, but it could potentially free up space in our clinics and waiting areas for patients who do need to be seen at the Institute."
Sara Tolaney, MD, MPH, director of the breast oncology clinical trials program and associate director of the Susan F. Smith Center, cites the flexibility that virtual visits allow. "One nice perk is that the patient can invite in whoever they want," she comments. "If a patient has a sister who lives across the country and wants to be part of an appointment, we can have her join in. I had a telemeeting with a patient who was in Boston, and her relatives from England were able to participate in this conversation with their loved one."
Online meetings are also helpful for sharing images and printed material with patients, Dr. Tolaney continues. "I'm able to share pathology reports, illustrations, and information on treatment protocols all via the computer. It's a very handy way to present information."
Sara Tolaney, MD, MPH, gained an appreciation of the advantages and limitations of telemedicine during the pandemic.
Despite some advantages, virtual visits cannot and should not replace in-person meetings, clinicians say. Physical exams, for example, cannot be conducted remotely (although some physicians foresee a day when patients can have their pulse and blood pressure measured from a device linked to their computer). Beyond that, some topics and discussions require a level of sensitivity and emotional presence difficult to establish online. "Sometimes it's really important that conversations be in-person," Dr. Tolaney remarks. "Even if it's a conversation you could have online, if it carries a big emotional weight, it helps to be in the same room as your physician."
Keeping Trials Open
The challenges of cancer treatment in the early days of the COVID-19 outbreak were especially prevalent in the area of clinical research. Clinical trials of potential therapies operate within a web of rules on everything from patient eligibility to quality control to data collection, many of which could be hampered by restrictions associated with COVID-19. Many hospitals responded to the additional burden by suspending clinical trials. Dana-Farber made a determination to keep its trials up and running during the pandemic, and keep patients enrolled.
Doing so required a degree of creativity and flexibility not usually associated with the rule-bound world of clinical research, where making even a minor adjustment to a trial protocol can be a major undertaking. Patients on trials of oral medications, who in the past had picked up the medication at the Dana-Farber pharmacy, had it mailed to them instead. Patients who needed blood work and would otherwise have come to Dana-Farber for it, had it done at a local lab. Meetings between clinicians and trial participants were held by videoconference wherever possible.
"We did everything possible to keep all of our trials open. Everyone who was on a trial had the opportunity to stay on it," says Ursula Matulonis, MD, chief of the Division of Gynecologic Oncology at Dana-Farber. "Additionally, if a trial hadn't yet started but had been submitted for approval by the Institutional Review Board (IRB), which reviews protocols for safety and scientific merit, we kept it in the queue for IRB approval, so that once the restrictions were eased we could open it up right away."
It was necessary to make a few concessions to the epidemic. Tissue collection and research biopsies, in which blood or tumor tissue is analyzed for biomarkers of disease, were temporarily suspended to preserve resources. And new trials didn't open while the highest level of COVID-related restrictions were in place.
Clinical trial leaders agree that telemedicine, home delivery of oral medications, and offsite laboratory testing are here to stay, to some degree, in clinical trials. The experience of conducting clinical trials during a pandemic may prompt investigators to take a fresh look at many of the traditional, perhaps overly rigid, aspects of clinical research, Dr. Winer says.
"Innovations like telemedicine and offsite testing have the potential to substantially increase the number of patients who can receive their care at Dana-Farber," he remarks. "If people know they can receive Dana-Farber care, but don't have to come to the Institute for every meeting with their physician, it could facilitate their decision to seek care here."