By Erin Emery, Todd Neff and Tyler Smith
If there is one thing James Darnley doesn’t need more of in his life, it’s challenges.
The 69-year-old Colorado Springs resident has stage 4 renal (kidney) cancer, which metastasized to his brain and lung. Darnley had a 2.5-inch tumor removed from his brain and lost his left kidney. After enduring chemotherapy to scour remaining cancer cells from his body, he finally got some good news in August 2018 from his oncologist, Dr. Robert Hoyer, at UCHealth Cancer Center – Memorial Hospital Central, who declared him cancer-free.
To keep the renal cancer from returning, however, Hoyer put Darnley back on a cancer-inhibiting drug in pill form called
Now, Darnley has another unwanted challenge. He is trying to keep a new intruder – COVID-19 – out of his life. He is one of many Americans staring down coronavirus with a weakened immune system, the body’s defense against disease.
“I’m here, that’s the main thing,’’ Darnley said. “This coronavirus, I’ve been kind of worried. I’m keeping a good attitude. That’s the best you can do, is keep up a good attitude.’’
Darnley is just one of many cancer patients caught up in a world scrambled by the SARS-C0V-2 virus, which causes COVID-19. Many require regular treatments, like chemotherapy, that can’t be done at home, which increases their risk of exposure to the virus. Others whose conditions are relatively stable must wait for procedures like surgery and radiation until the massive crush of COVID cases eases pressure on hospital resources. And for patients facing the physical and emotional drain of cancer, physical distancing can increase already heightened feelings of loneliness and isolation.
It all makes for a delicate balancing act. Evidence shows that patients who maintain their prescribed regimens of treatment have better outcomes. That’s why UCHealth cancer centers across Colorado, continue to provide care every day for patients who need critical infusion, radiation and surgical treatments.
At the same time, Hoyer said, “We know that cancer patients are at higher risk of becoming infected because of immunosuppression. It’s difficult to know how much, but all of the data says cancer patients are at higher risk. The biggest concern right now is to ensure patients have access to their diagnostic testing and treatment services without risk of exposure to the coronavirus.’’
The question is how best to do that. In some cases, providers at UCHealth can offer virtual visits via a computer or mobile device connection and a My Health Connection account. That allows them to continue their care and stay at home safely. The real-time encounters can be through either a video hookup or email messaging.
At UCHealth Highlands Ranch Hospital, Dr. Radhika Acharya-Leon, a University of Colorado School of Medicine cancer specialist and the hospital’s chief of Oncology Services, said the oncology team is using telehealth to minimize direct outpatient encounters when it is feasible and clinically appropriate to do so.
Acharya-Leon said she still sees some patients on-site, but now conducts telehealth visits two days a week. The hospital’s transition has gone well, thanks in part to a crash telehealth training program for UCHealth providers and staff, she added.
Like a face-to-face encounter, the appointments may start with a medical assistant, working remotely, who speaks with patients ahead of time to review symptoms, make changes in history, review medications, and complete other necessary tasks. Physicians then conduct a virtual office visit from another location.
Holding the line
During normal times, Oncology Services at Highlands Ranch Hospital includes an inpatient unit, an outpatient clinic an infusion center, genetic counseling, social work, and radiation oncology. In the wake of COVID-19, the usual on-site clinical team of 30 has been sharply reduced, with nutritionists, social workers, and geneticists working from home when possible. Nurses rotate from onsite to telehealth work, as Acharya-Leon does.
That’s for the protection of patients, of course, but also for providers and staff, she said. “We’re reducing our exposure to the office environment because if one of us gets it, we’re all out.”
Of course, patients still need direct care, including chemotherapy infusions and radiation. Clinics have had to take new precautions to protect cancer patients from virus transmission while ensuring that they get lifesaving care, Hoyer said.
“It is really important that we try to main our level of care as close to normal as possible,’’ he said. But the risk of COVID-19 demands increased safety measures, he added, including taking steps to minimize waiting-room time and keeping patients separated by at least 6 feet in clinic areas.
Those changes help to illustrate the dilemma that COVID-19 poses for cancer patients and providers. The pandemic has not eliminated the need for patients to get chemotherapy infusions in clinics and hospitals, and new patients are understandably eager to start care quickly, Acharya-Leon said. But chemotherapy suppresses the immune system, leaving patients more vulnerable to COVID-19. A chemotherapy regimen requires multiple hospital visits, increasing the accompanying viral transmission risk.
Yet that risk must be balanced with the potentially disastrous effect on survival of stopping treatment, Acharya-Leon stressed. It’s a quandary that has brought about “heavy discussions and dialogue” that neither the patient nor the provider typically have when the norm is to treat no matter what. The talks, however, can be positive, Acharya-Leon added.
“It’s an incredible opportunity to talk about quality of life, survival, and risk,” she said. For example, those patients who have been in treatment have largely agreed that it’s smarter to push off routine scanning a month or two, assuming Acharya-Leon and her colleagues decide that the risk of a sudden change in status is low.
Keeping the connection
Acharya-Leon and Hoyer said they continue to stress to their patients the importance of protecting themselves from the coronavirus through physical distancing. But they said it’s vital for patients to also care for themselves by maintaining social contact with friends and loved ones. FaceTime, Zoom, Skype and other applications can play an important role in keeping human connections strong and providing important motivation during challenging times, Hoyer said.
“Staying in touch with people can help lessen feelings of loneliness and depression,” he said.
“It is definitely important that we all support one another at this time,” Acharya-Leon added. She noted that patients who feel overwhelmed in simultaneously battling their disease and the challenges of everyday life can contact social workers and chaplains at the hospital for additional help.
The coronavirus has highlighted the importance of social connection in another surprising way, Acharya-Leon said. She and other providers in Oncology Services wear masks to protect themselves and their patients in face-to-face encounters. The essential safety measure, though, has proven for some patients to be a troublesome barrier to communication
“We’re having these difficult discussions with a mask on,” Acharya-Leon said. “Patients can’t see your face or your expressions. Everything’s blocked except the eyes.” One patient who had struggled with renal cell carcinoma for years tearfully asked her to step back a couple of feet so he could see her face when she gave him some good news about his disease.
“I want to see you smile when you give me the good news,” the patient told Acharya-Leon.
The long road back
So far, the news for James Darnley is good. He remains cancer-free and said he adheres to his chemotherapy regimen, as well as Hoyer’s instruction to maintain physical distance.
“I haven’t been out for several days, and my friends and family are bringing me groceries,’’ he said. “I’m not going to do anything to let [the virus] pull me down.” A few days ago, Darnley wrote out the words to the Lord’s Prayer on his Facebook page. Most of those who commented said only one word: “Amen.’’
For her part, Acharya-Leon believes some good can come from the response to COVID-19 of patients like Darnley and caregivers in oncology and the entire health care system.
“It’s been an interesting time. Our staff has been just remarkable. Our patients have been incredibly appreciative and grateful that we’re on the front lines doing what we’re doing,” she said. “It’s a rare opportunity for the world to really see what health care is, what it can do, and the importance of caregivers.”