Cancer Care During the COVID-19 Pandemic

PTCE would like to acknowledge Merck Sharp & Dohme Corp. for their generous support of pharmacist education.

The keynote session at the 2020 Directions in Oncology Pharmacy^® conference was titled Changes in Cancer Care: Practicing Pharmacy in the Era of COVID-19. David DeRemer, PharmD, BCOP, FCCP, FHOPA, summarized the impact of the COVID-19 pandemic on both cancer patient outcomes and care delivery models. While the pandemic has posed many challenges, Dr DeRemer encouraged the audience to identify opportunities to extend or expand pharmacy services in the ambulatory setting or via virtual care delivery models.

Dr DeRemer began with a sobering look at outcomes of patients with cancer diagnosed with COVID-19. Reports from China, Europe, and the United States indicate patients with cancer are at higher risk of severe events and death from COVID-19. Patients with active hematologic malignancies appear to have a higher likelihood of death with symptomatic COVID-19 infection compared with patients with solid tumors.

Dr DeRemer illustrated delays in diagnosis, surgery, radiation, and chemotherapy due to the COVID-19 pandemic. Delays in cancer care coupled with a shift in treatment strategies toward less-intensive approaches are expected to increase cancer mortality by at least 10,000 deaths from breast and colorectal cancers over the next 10 years. Physician survey responses indicate providers have decreased prescribing of immune checkpoint inhibitors, monoclonal antibodies, and corticosteroids during the pandemic.

Dr DeRemer provided examples of appropriate modifications to chemotherapy during the COVID-19 pandemic, including substituting infusional fluorouracil with oral capecitabine in patients with colon cancer, reducing total treatment duration in patients with breast cancer, and using extended interval dosing of immune checkpoint inhibitors. He emphasized the short-term recommendation to expand use of white blood cell colony-stimulating factors (CSFs) for patients receiving chemotherapy regimens with a febrile neutropenia risk of greater than 10%. He noted CSFs should be discontinued in patients with a confirmed or suspected COVID-19 infection to avoid the possible risk of increasing pulmonary inflammatory cytokines.

Clinical trial screening and enrollment also fell significantly at the start of the COVID-19 pandemic and has not recovered to baseline. Dr DeRemer highlighted changes that facilitate clinical trial participation during the pandemic, including use of telehealth, electronic signatures, remote laboratory monitoring, and shipping medications to patients’ homes.

The COVID-19 pandemic has accelerated both acceptance and payment of novel care delivery models including telehealth. Dr DeRemer provided examples of oncology pharmacists using telehealth to monitor oral oncolytic adherence and adverse effects and to manage supportive care and post-transplant medications. Although the COVID-19 pandemic has transitioned some types of care to the home, Dr DeRemer emphasized this is not always appropriate. The American Society of Clinical Oncology has directed that home infusion of chemotherapy should be limited to exceptional circumstances where benefit outweighs risk. He noted publications are emerging about care models successfully delivering maintenance monoclonal antibodies, immune checkpoint inhibitors, and bortezomib at home.