No Guides and No Lines: Cancer Care During COVID-19

Narjust Duma, MD

As oncologists, we often rely on guidelines to make treatment decisions, to pick the best approach for our patients, and to decide when and if surveillance scans are necessary. However, none of those guidelines include dealing with a pandemic such as COVID-19.

Many of our decisions are now based on when the virus-surge is happening and how we can keep our patients away from hospitals. We also lack guidelines on how to help our patients cope with their newfound isolation and this new way of life. We do not have a script, no flow charts, and no citations.

Data from our colleagues who have faced the virus before us are rapidly being published; these data come from their experiences, from their losses. Many of these articles are very informative and humanizing, but the majority do not apply to our unique healthcare systems in the United States. We lack universal health care, and not everyone has access to physicians, testing, and medications.

During medical training, emphasis is always placed on evidence-based medicine. I remember citing meta-analyses during rounds, seeing the look of approval from my attending physician, and receiving compliments because “I have reviewed the data.” In 2020, there are no meta-analyses to cite and high-level evidence-based guidelines to follow. We are more on our “own,” than ever before, and I will even go so far as to call this a new type of “precision medicine” that we are practicing. We are tailoring our treatment decisions not only to the histologic type or PD-L1 expression of a tumor, but also to the risk of developing complications if our patients become infected by the virus, our patients' ability to practice social distancing, as well as their financial stability while staying at home.

Large societies are creating guidelines to help physicians make these decisions, but as with many other guidelines, one size does not fit all. One senior physician said to me a few days ago, “We are becoming real doctors again,” But are we really? Is guessing treatment decisions becoming a real doctor? I do not have an answer to that, but I can say that this whole experience has been incredibly humbling. The words “I do not know” are often said during each patient encounter. Those words are the pure truth during this healthcare crisis: We do not know, but we may know many months from now.

I do have to say that the lack of high-level evidence is anxiety-provoking and often keeps me awake at night. How can I know if I am making the right decision? Can I extrapolate these or those data to my patients? We no longer have a map and need to rely on our instincts. Is that what becoming a real doctor means? The fathers of modern medicine like Hippocrates and Democritus used to rely on their instincts to practice medicine, but they also used to phlebotomize patients for headaches.

Listening to colleagues and patients have become the new guidelines. The sense of isolation is alleviated a bit when we share and discuss difficult cases with our colleagues; we are functioning as a large and continuous tumor board. We learn from each other’s experiences and we make decisions based on collective thoughts. We have also incorporated our patients’ comfort level into our recommendations. While this should always be part of our clinical decisions, questions like “Are you comfortable coming to the clinic?” or “How do feel about postponing scans for a few months?” have been introduced into daily conversations that we’re having with our patients. These have become our “new” treatment guidelines.

Many questions remain unanswered but working as a team provides us with some comfort as we determine our new approach for decision making in daily practice. I hope this practice does not evaporate as we overcome these dark times. We are better oncologists when we work together. We are better physicians when we listen to our patients' concerns, and we are better human beings when we accept that sometimes, we just do not know.