CEDAR RAPIDS — Darrell Gear is one of the few patients who still regularly go to Mercy Medical Center — which, like other hospitals nationwide, has locked down its facility to restrict the public for the foreseeable future.
But Gear’s care can’t wait. The 75-year-old Swisher resident, who has been fighting cancer on and off for about three years now, has been receiving chemotherapy for cancer that was discovered in his bladder.
“The main thing with me with this (coronavirus), it’s like cancer,” Gear said. “There’s no cure. So people like me, we have to be very conscious of what’s out there. We have to try to protect ourselves from whatever it is.”
As area hospitals put elective surgeries — including many surgeries for cancer patients — on hold to focus on COVID-19, area oncologists have adjusted their plans, leading them to take different approaches to patients’ cancer treatment.
At the same time, doctors also are juggling the risk to patients like Gear — who are immunocompromised and could face severe complications from a coronavirus infection — as they enter their facilities for treatments.
“We do not help a cancer patient if somehow they end up with coronavirus, but we also don’t help patients if they don’t get adequate treatment for their cancer,” said Dr. Deb Wilbur, an oncologist and hematologist at Mercy Medical Center in Cedar Rapids. “It’s a delicate balance, keeping patients as safe as possible, but still giving them adequate treatment.”
Area doctors have adjusted cancer treatments in ways, based on studies and recommendations from national medical societies, that ultimately will not affect a patient’s long-term prognosis. No matter the adjustment, the chance of being cancer-free in five years should remain the same, experts say.
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However, there is a general concern among some that delaying routine screening — such as mammograms and colonoscopies — could lead to more advanced cases once the pandemic clears.
“That delay could make a difference,” said Dr. Rasa Buntinas, a Physicians’ Clinic of Iowa oncologist and hematologist.
“We are concerned,” University of Iowa professor and Cancer Center Director George Weiner said recently during a virtual discussion on COVID-19’s impact. “We obviously would prefer not to have to delay these at all. On the other hand, a lot of cancer screening takes place yearly, every five years, and delaying those a few months really is unlikely to have a major impact.”
Weighing need for PPE
The UI Holden Comprehensive Cancer Center has moved some of its work and education online, curtailing student involvement with patients “unless their participation enhances that patient care.”
“We have canceled many elective visits of our patients and procedures that can be put off safely, while obviously continuing to care for patients that need care now,” Weiner said in the virtual discussion.
“We’re postponing and holding virtual video visits, when appropriate, but we’re also very busy treating patients,” he said. “Because cancer doesn’t wait.”
The center’s tumor boards, for example, are meeting online.
“And then other clinical activities we’re holding off on, such as cancer screening,” Weiner said. “That can wait until after this episode has passed.”
Treatments like chemotherapy and radiation are still ongoing at other Corridor hospitals, but for the most part, surgeries are delayed.
For breast cancer patients, that may mean doctors delay a mastectomy and control the cancer through chemotherapy or radiation treatments. But even if a mastectomy is performed at this time, reconstruction and other nonemergency plastic surgeries are suspended for now.
Dr. Kerri Nowell, a surgeon with PCI, said surgeons can’t justify using the amount of personal protective equipment needed, and the required hospital stay after the surgery could put the patient at risk.
If no other option remains available and the surgery is necessary for the patient’s survival, the surgery would proceed, Nowell said.
A board representing both Cedar Rapids hospitals, PCI, Surgery Center Cedar Rapids and Linn County Anesthesiologists has approached this unprecedented scenario as a citywide issue. The board meet remotely to discuss specific patient cases, weighing the necessity of the surgery with the availability of ventilators and personal protective equipment in local hospitals.
So far, the board has not turned down a request to proceed with surgery, Nowell said.
Surgeons with Mercy Iowa City also are following guidance from entities like the American College of Surgeons as to which procedures should occur and which should be delayed, “or what the timing of surgery should be in the best interest of each patient.”
“All are cognizant of the restrictions on surgery because of national guidelines to protect patients and caregivers,” said spokeswoman Margaret Reese. “Once a surgery has occurred following a diagnosis, the specific course of treatment for that patient is followed.”
As each patient case is unique, officials with Mercy Iowa City say providers are deciding on an individual basis “whether treatment can be safely delayed because these patients are at higher risk.”
For patients undergoing radiation and chemotherapy treatment, doctors are considering how to change the regimen to limit the number of times a patient has to come for appointments.
In some instances, patients can be given a dose more frequently or even receive twice the normal dose at the same frequency, said Wilbur of Mercy in Cedar Rapids. The patient may experience more gastrointestinal symptoms, “but it’s worth it if we can cut in half the number of times they walk through the building door.”
Impact on research
From a research perspective, Weiner said, his center has paused a lot of activity — with between 30 and 40 studies on hold.
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“Our clinical research activities are being limited to just those particular exciting new treatments that we think have the potential to help patients,” he said, stressing, “We’re continuing to develop new cancer treatments and provide them for our patients.”
More than 120 clinical cancer trials are continuing through the UIHC’s pandemic response, primarily those involving treatments that are so new or experimental they can be obtained only through a clinical trial, Weiner said.
“We have patients on those treatments, some of whom are doing well, and it would be unethical to stop those studies,” he said. “Those trials where the patient is getting a unique treatment because of the trial, those we’re doing our best to keep going.”
As for new cancer-related research — which was exploding before COVID-19 hit — the university is doing its best to continue, even if some researchers aren’t allowed in their labs.
“I was recently reading about Sir Isaac Newton, who actually came up with many of his theories of gravity and calculus when he was in isolation during the plague,” Weiner said. “So there are things that can happen, and the research is continuing, despite the challenging times.”
But with curtailed clinical visits and suspended activities, Weiner warned financial implications will be major.
“We’re canceling patient visits, and obviously the revenue that would come from those patient visits is going down,” he said. “Elective surgeries are no longer being done, so the operating rooms are quiet … That is going to have a big impact on the finances, from the medical side.”
Most funding organizations are continuing to support research grants, based on the understanding researchers are still working — even if not in the lab. But Weiner added philanthropic support right now is “even that much more important.”
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“It’s going to allow us to keep going, and it’s going to allow us to gear back up once this crisis passes.”
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