Telehealth

The social distancing since the U.S. public health emergency (PHE) declaration on March 16, 2020, lead to rapid implementation of telehealth strategies to care for patients at home. The PHE required payors and insurers, including Medicare and Medicaid, to cover telehealth at the same rate as a face-to-face visit. Telehealth visits spiked during the early phase, peaking around April 15 and declining by June 10, 2020.

Health care has responded with new technology-based tools to make navigating the experience a little easier and prevent people with cancer from unnecessary exposure to possible COVID-19 infection in hospitals and emergency rooms. For example, telehealth and remote interactions with the oncology team have improved patient access and enabled family members to more easily participate in cancer care. However, it’s also highlighted disparities in care: not all people have the knowledge of or access to technology to use telehealth.

Scope of Practice

Under the PHE, advanced practice providers gained full scope of practice across the United States, enlarging the workforce and reducing barriers to interstate care. Prior, full scope of practice was only authorized in 23 states plus the District of Columbia and Guam. It enables oncology advanced practice RNs to bill for patient care without physician supervision, reaching patients for survivorship care, symptom management, patient education, and support.

Vaccinations

Vaccines against COVID-19 have progressed rapidly through Operation Warp Speed. The U.S. Food and Drug Administration gave two novel mRNA vaccines Emergency Use Authorization in December 2020, and more are in clinical trials. SARS-CoV-2, the pathogen that causes COVID-19 infection, has several strains and variants. The vaccines were tested and are 95% effective in the strains and variants circulating at the time of the clinical trials; however, new ones are emerging. The U.K. (B.1.1.7) and South African (501.V2) strains have protein-based genomic differences that may make the vaccines ineffective. Scientists are investigating to refute or confirm the theory.

Healthcare providers are prioritized for phase 1a vaccination; people with cancer, considered at high risk, are scheduled for later phases. National and international organizations such as the American Association for Cancer Research, American Society of Clinical Oncology, and American Cancer Society have advocated for offering vaccination to people with cancer despite their exclusion from the vaccine trials because the benefits outweigh the harms of infection. However, questions remain as to whether immunocompromised patients (e.g., stem cell transplant recipients) can mount an immune response after vaccination.

The National Cancer Institute has a Q&A about COVID-19 vaccination in patients with cancer.

Cancer and COVID-19

Increased risk: Certain patients with cancer are at greater risk for serious COVID-19 infections and even death. Researchers found an overall 21.2% increased mortality rate for people with cancer and COVID-19, compared to 8.7% in the noncancer group. The risk is highest among men and those with comorbidities such as obesity or hypertension. Those with a smoking history had a 31.1% higher mortality risk.

Independent factors associated with increased 30-day mortality in people with cancer and COVID-19 are older age, male sex, smoking history, two or more comorbidities, Eastern Cooperative Oncology Group performance status of 2 or higher, and active or progressing cancer.

Cancer screenings: Adherence to routine and follow-up cancer screenings (e.g., mammography, colonoscopy) decreased markedly during spring 2020, almost 80% for breast and colorectal
cancer screenings alone. Added to the cancellation or postponement of elective surgeries, the delays may lead to more late-stage diagnoses, poorer responses to treatment, and increased mortality over the next 10 years.

Cancer clinical trials: Clinical trials have been halted or delayed, slowing progress in the development of new therapies for cancer and affecting future outcomes. However, some of the U.S. government-waived adaptations to clinical trial designs have improved access, such as electronic consent and home delivery of trial medications.

Cancer experience: Because of social distancing restrictions, more people with cancer and their families have struggled with isolation. Family members and caregivers are not permitted to accompany patients into hospitals during inpatient stays or into infusion centers during treatment. Often, cancer survivors have had their care postponed and follow-up tests delayed, increasing their worry about a cancer returning or a new cancer emerging. Oncology nurses have an opportunity to develop programs to address isolation, emotional well-being, and other disparities among patients with cancer.

COVID-19’s Effect on Nurses

The drastic changes COVID-19 brought to life in general and cancer care have also been felt in the nursing profession. Many nurses were shifted to inpatient or COVID-19 units, took on new telehealth and triage responsibilities, and faced moral distress when caring for people with COVID-19. Some have been furloughed or had their hours reduced. Throughout it all is the underlying concern of being infected by the virus and bringing it home to their families and communities.

Because patients arrive for outpatient care without family or caregivers, nurses must provide support and reassurance, use technology to include family members in education, and facilitate communication between the patient, oncology team, and family. On top of that, nurses must follow new infection risk and control procedures, adding burden and strain to their already-demanding jobs.

In response, the International Council of Nurses’ Mental Health Core Guidance and Recommendations for Nurses called for healthcare systems to support nurses’ mental health and well-being: “To support a nurse’s personal resilience under such stressors requires all parts to actively support and build resilience across teams and the health service system.” See this ONS Voice article for strategies for health systems to support providers' mental health.

Future Opportunities

COVID-19 will continue to disrupt society and cancer care in 2021, but the arrival of vaccines brings hope for decreased serious infections. Better control of the virus will improve access to cancer care, including screening, treatment, and survivorship care. As a nation, we have made rapid progress on vaccine development and nurses, as the most trusted profession, can dispel myths, advocate for vaccinations, and protect their patients and families.

Oncology nurses must advocate for safe cancer care services; vaccination for patients at risk; infection control measures such as masks and personal protective equipment (PPE), distancing, and handwashing; and resources to manage the mental health burden.