For almost five years after her treatment for breast cancer, Desiree Harmon made an inconvenient, monthly trek to the Hospital of the University of Pennsylvania for an injection that helps keep the disease from coming back.
“I called it my calendar-killer,” the 45-year-old middle school director at Friends Select said of her West Philadelphia appointments. “I had to work my life around this shot."
The pandemic changed that. Because hospitals are hot zones of coronavirus transmission, Penn is ramping up home cancer care. A nurse now gives the estrogen-suppressing shot to Harmon at her home in Mount Airy, where she, her husband, and their two children are hunkered down.
“I kind of freaked out a little bit [about coronavirus] because of having a compromised immune system," Harmon said. “As much as I love Penn, not having to go there gives me peace of mind.”
COVID-19, which has so far killed more than 28,000 in the U.S., is particularly dangerous for older adults and those with weakened immune systems; cancer patients are often both.
That’s why hospitals, oncologists, and insurers are beginning to look for ways to shift cancer treatment out of medical facilities, including the “infusion centers" where outpatients sit for hours getting intravenous chemotherapy.
Just earlier this week, the National Comprehensive Cancer Network, an alliance of 30 leading cancer centers, issued these recommendations in response to the pandemic: Try to convert in-person oncology visits to telemedicine. Use oral chemotherapy whenever possible. Move outpatient care, such as disconnecting infusion pumps and giving injections, into the home. Do scans less often, or switch to blood tests for monitoring response to therapy. The guidance also has advice for ensuring the safety of oncology care workers.
At Thomas Jefferson University Hospital, the strong telemedicine program has been expanded to reduce oncology patient visits to the Center City institution.
“Yesterday, I saw only four patients in person. I saw 10 online,” said Jefferson oncologist Adam Binder. “Even patients who come to the infusion center for chemotherapy are seeing the providers the same day via telehealth to reduce time and touches in the center.”
For their part, patients are justifiably afraid that coronavirus exposure may be more dangerous than postponing cancer treatment.
“We get a lot of calls every day asking if it’s necessary to come in,” Binder said. “Patients are canceling on their own or their families are canceling, even if we think it is medically necessary.”
Cancer care has traditionally been provided in medical facilities for good reasons. Infusion centers can efficiently give chemotherapy, including complicated drug regimens, to large numbers of patients while monitoring them for bad reactions that require quick intervention. Hospitals are primed for emergencies such as severe nausea, dehydration, blood clots, difficulty breathing.
The problem is that Medicare — which pays $30 billion to treat beneficiaries with cancer in their first year after diagnosis — and private insurers often won’t reimburse for treatment outside those proven settings, even when it seems sensible.
The pandemic is accelerating revisions in reimbursement policies, said Justin Bekelman, director of Penn’s Center for Cancer Care Innovation.
“Some reimbursement mechanisms already exist for [home] services or are in process," he and a colleague wrote in a journal article. “For example, billing codes for home infusion of intravenous fluids or medications, including chemotherapy, are present, and the home infusion market is growing rapidly. Forty-nine states and Washington, D.C., have legislation related to payment for some telemedicine services.”
Late last year, the cancer care innovators planned a home treatment program in partnership with Penn’s pharmacists and home infusion therapists.
Launched in February, the pilot program soon signed up several dozen patients with breast cancer, prostate cancer and lymphoma. Six cancer drugs not previously given in the home, as well as a complicated five-drug regimen called EPOCH, were successfully administered.
Then, in mid-March, state officials began issuing stay-at-home orders, while the surge in coronavirus patients overwhelmed many hospitals. The number of Penn cancer patients getting home infusions jumped from 670 in mid-February to 845 now, Bekelman said, adding that 15 additional cancer drugs are being considered for home delivery.
Given that Penn performs hundreds of cancer infusions a day at its West Philadelphia complex, home care is still “tiny,” said Penn oncologist Lynn Schuchter.