We are facing a surge in corona virus cases. Hospitals are at their limits throughout the United States. Nurses, doctors, hospital staffs are overwhelmed. They are tired, and relief is not in sight.
Does that mean we will start seeing health care rationed, especially for cancer patients whose prognosis may be uncertain? Sadly, that may be the case over the next several weeks if we don’t reverse our current course to disaster.
During the early days of the COVID19 pandemic one of my worst fears was the possibility that cancer patients could not get hospital treatment if needed as a result of limits placed on care in the face of severe resource shortages. Burdens on hospitals and health care workers were intense, and if we reached a crisis point—as occurred in New York City—the possibility existed that cancer patients could find themselves denied care in favor of others without life-threatening illnesses.
Fortunately, that scenario did not come to pass—at least not visibly as feared. But that doesn’t mean it couldn’t happen during this current surge.
An article and editorial published online in JAMA Oncology take on the question of what formal rules states have put in place to triage medical care during a crisis situation. The rules are called “Crisis Standards of Care” and although not every state has one, for those that do the rules may be very explicit that cancer patients may be denied care under certain circumstances in favor of those who have a better chance of survival.
It won’t be a choice. It will be the law.
The authors found 31 states had these triage guidelines in place, some more specific and detailed than others without much consistency across the various documents when it came to how rationing decisions were made. In states where there was a comprehensive cancer center the recommendations tended to have a more open-minded approach to how cancer patients would be treated under these worst case scenarios. Some states, however, had “categorical exclusions” when it came to patients with cancer—meaning that some patients with cancer could not get medical care beyond keeping them comfortable in a crisis situation. One state (Montana) even deprioritizes those people with a “malignancy with a <10 year expected survival.”
As pointed out by the authors, making predictions about the survival of someone with cancer is not so simple. There is no chart that gives accurate information for any particular patient. Yes, in some sad circumstances a patient with a cancer diagnosis may be near death. However in many other situations a patient with a diagnosis of cancer may be receiving intense treatments with an excellent or reasonable expectation for long term survival. In other words, appearances aren’t everything.
A moment in time does not portend the future for a patient with cancer, especially given new treatment options.
Recently, metastatic melanoma was a fatal diagnosis with short term survival. Now, survivals over 5 years are not uncommon. Ditto for lung cancer: formerly a death sentence, we are just beginning to see the impact of targeted and immune-therapies on improving the outlook for patients with metastatic disease. And a diagnosis of metastatic breast cancer does not mean immediate demise. Many women can live for years with the disease especially given some of the new treatment approaches that are available.
The editorial asks the broader question about how patients with cancer will fare during the COVID-19 pandemic, given not only the concerns about care during the surges we have experienced but also the fact that diagnoses have been delayed and general medical care has been impacted in so many ways since the pandemic began.
The sad reality is that once again we are facing the very real possibility that routine medical care may be limited as we start to see communities go into formal lockdown as in California, or people begin to voluntarily withdraw as a result of their concerns about the pandemic. I fully agree with the editorial authors’ concerns that it will take us years to assess the impact of the pandemic on the outcomes for patients with cancer—and what we learn will be disheartening to say the least.
As noted in the editorial:
“As a group, patients with cancer can be vulnerable to the significant shifts in the health care delivery system brought on by COVID-19. The impact of delayed or denied screenings and diagnostic workups as well as suboptimal or delayed treatment may take years to fully reveal themselves. However, the potentially significant impacts on patient outcomes go well beyond those called for in some state CSCs. We must be vigilant in our efforts to take care of our current and yet to be diagnosed patients with cancer or they will risk becoming additional, unnecessary deaths caused by COVID-19.”
As I write this, we are facing a mounting disaster in the United States as a result of surging COVID-19 cases. Our hospitals and those noble, committed health professionals and staff that care for patients in those hospitals are overwhelmed. They are tired, they are frustrated, and they know it isn’t getting any better. We have a terribly dangerous road ahead of us, a COVID winter that will rival any public health crisis this nation has ever seen.
We can debate how we got here, and we will debate why we haven’t taken the personal measures that would get us out of this mess. I am frustrated every day trying to understand why people don’t get the message about what they can do to help mitigate the problems we are facing, and why they don’t understand the tragedies that are happening all around us.
However, our reality is that we are where we are and if there isn’t a massive change in our behavior we aren’t going to see improvement for months to come. And if this surge continues—as it likely will—what we will see is hospitals starting to cut back on elective medical care and surgeries, and when everything backs up we will start to see health care rationing. And for cancer patients, that could mean death instead of life, especially if they fall ill with the virus.
No doctor, no nurse, no health professional wants to make a decision to deny needed care. No loved one, no friend, no colleague, no acquaintance wants to hear that someone died not from their underlying disease but because they couldn’t get the medical/hospital care they needed since others were considered a better bet for surviving their illness.
That’s what rationing means. It is not something that is “out there” that can never happen. States have plans in place because a disaster very clearly could happen and that disaster is going to require medical teams to make decisions in a split second on who lives and who dies. It happens in war; it could happen at home if we don’t get this pandemic under control.
No one ever wants to make that decision to deny life simply because another human being has a diagnosis of cancer. If we don’t get this pandemic under control there may not be an option.