Cancer treatment in pandemic

On the eve of a chemotherapy appointment, Teri Woodhull has blood drawn by nurse Kim Rohde at M Health Fairview's Lab Draw Hub on July 15, 2020 in Minneapolis. After the blood draw, Rohde secured the port that will be used for chemotherapy. (Jeff Wheeler/Minneapolis Star Tribune/TNS)

MINNEAPOLIS - As COVID-19 deaths peaked this spring, Teri Woodhull faced a tough decision on treatments for cancer - a condition that already makes her more vulnerable to the pandemic.

Woodhull could lower her risk of being exposed to the coronavirus by undergoing chemotherapy every three weeks, rather than weekly. But less-frequent treatments are delivered with a stronger dose, raising the possibility of more severe side effects.

"When you're going through treatment for cancer, it's emotional already," said Woodhull, 57, of Minnetonka, who was diagnosed with advanced ovarian cancer in 2010. "When you layer on the stress of not knowing whether the choices you're making might be endangering you even more _ it just piles on."

For cancer patients in Minnesota, COVID-19 has altered treatments, paused clinical trials and limited connections with friends and family in the midst of a dreaded diagnosis. Thousands of mammograms and colon­oscopies were delayed in March and April as hospitals and clinics marshaled resources to fight COVID-19.

Now, as the health care system slowly returns to pre-COVID norms, doctors are uneasy because patients seem to be steering clear of care, despite reassurances about the safety of health care facilities. One possible consequence is that cancers will be caught later, when treatment options are more difficult.

"A delay of six weeks is probably not going to have a significant oncologic outcome impact or change for any individual patient or even a population," said Dr. Natasha Rueth, a cancer surgeon at Allina Health System. "I'm more worried about the downstream effects of people not coming into the health care system now, and what that's going to mean for future cancer patients."

To conserve supplies for treating COVID-19 patients, Minnesota joined other states in halting elective and nonemergency medical procedures, beginning the evening of March 23. The ban was lifted about seven weeks later, on May 11.

States also issued stay-at-home orders this spring, which further contributed to cancer patients staying away from health care, said Dr. Norman Sharpless, director of the National Cancer Institute, in an editorial in the journal Science. He projected that COVID-19 could result in almost 10,000 excess deaths _ an increase of about 1% _ beyond the expected toll from breast and colorectal cancer over the next decade.

Some doctors and public health experts question the projections, in part because there is controversy over the net impact of cancer screening. But concerns are growing, nonetheless, that patients are avoiding cancer care in ways that could have harmful consequences.

New patient consults and newly diagnosed cancer patients are down more than 20% compared with the same period a year ago, say doctors with Minnesota Oncology, a group of 55 cancer specialists with 12 offices across the Twin Cities. They've begun seeing more late-stage cancers relative to prior rates, as well.

"Now that we're six months into this pandemic, delayed screenings are becoming a public health issue," said Dr. Paul Thurmes, the medical director with Minnesota Oncology.

Delayed treatment

At Allina Health System, about 7,500 mammograms were delayed between March and May. In general, a majority of breast cancers are likely to be slower growing, Rueth said, and would not go from curable to incurable, or even significantly advanced, in two months.

But she added: "We know that a lot of women aren't coming in."

Thousands of colonoscopies have been delayed at MNGI Digestive Health, which operates seven surgery centers across the Twin Cities. The test screens for colon cancers that often are slow-growing, so a delay of a few months shouldn't be risky in most cases, said Dr. David Perdue, chief medical officer.

Even so, missed appointments are troubling because short delays can snowball into longer ones.

"They were on the cusp _ the doctor finally had them talked into it _ and then this happened," Perdue said of COVID-19. "It's another (reason) to not do it, or delay it some more."

Cancer patients have missed out on clinical trials since studies were paused in part to reduce exposure risks, said Dr. Britt Erickson, a gynecologic oncologist at the University of Minnesota. The U tried to keep open, or reopen as quickly as possible, those studies that offered the most patient benefits by providing access to promising experimental treatments, Erickson said.

Researchers have been slower to resume studies that primarily offer benefits down the road _ such as Erickson's study of whether a hormone therapy helps slow tumor progression for patients with endometrial cancer. But those moves have long-term consequences.

Woodhull, the cancer patient from Minnetonka, isn't alone in having to consider COVID-19 risks when making decisions about chemotherapy options, said Dr. Andrea Wahner Hendrickson, a cancer specialist at the Mayo Clinic. Choices are tougher now because doctors and patients must consider how some regimens do more to suppress the immune system.

"There's a whole new level of risk that we didn't have to worry about before," Wahner Hendrickson said. "We know that our cancer patients, if they come down with COVID, are likely going to have a more difficult course."

Communities usually rally around newly diagnosed cancer patients, with friends making meals and families visiting regularly. But the need for social distancing with COVID-19 makes it harder for them to provide support. It gets even more complicated for cancer patients who are nearing the end of life.

"Obviously, we want people to follow (public health) guidelines," Wahner Hendrickson said. "But if you know someone is terminal or on hospice, finding that balance to make sure that they are seeing their loved ones and having those quality times _ stress and anxiety wise, that's really been tough on our cancer patients."

Compounded trauma

Kris Nozal is thankful her support groups through Gilda's Club and Pathways are still available online, but she misses the personal connections.

"It's a very sad adjustment to lose your normal life to cancer," said Nozal, 48, of Burnsville. "And now, the uncertainty of how long COVID will be a threat, pushes that ... sadness, fear, frustration and helplessness to a whole new level."

Kate Beesch felt the isolation as she underwent a biopsy in March, when visitor restrictions meant her sister couldn't stay in the recovery room.

"It's one time when you'd really like to have support from your family," Beesch, a 38-year-old Minneapolis resident, said of receiving the cancer diagnosis that day. "You're in a pandemic and you also have cancer; and you want to treat your cancer but you also don't want to get the virus. It's like compounded traumas."

This spring, when Woodhull had to decide on chemotherapy options, she opted for less frequent treatments to help minimize her COVID-19 exposure.

On Wednesday, in preparation for chemotherapy, she visited a special lab in Minneapolis at M Health Fairview for blood work. The facility was created since the pandemic started, specifically to lower infection risks for patients with cancer and other high-risk conditions _ an example of how health care facilities are doing "an extraordinary job in trying to protect us," Woodhull said.

Woodhull regularly attends virtual meetings with patients who agree COVID-19 has amped up the stress of cancer _ which is particularly bad, she says, since some research suggests lower stress correlates with better cancer outcomes.

"Cancer stinks. COVID stinks," said Woodhull, who is a board member with the advocacy group Minnesota Ovarian Cancer Alliance. "When you layer the two together, it just makes my cancer that much harder to deal with."

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