Caroline Hopkins | Vox Our world has too much noise and too little context. Vox helps you understand what matters. 2020-03-27T21:37:34+00:00 https://www.vox.com/authors/caroline-hopkins/rss https://platform.vox.com/wp-content/uploads/sites/2/2024/08/vox_logo_rss_light_mode.png?w=150&h=100&crop=1 Caroline Hopkins <![CDATA[Covid-19 patients are flooding New York hospitals, and the peak may be 3 weeks away]]> https://www.vox.com/2020/3/27/21197400/new-york-covid-19-hospitals-coronavirus 2020-03-27T17:37:34-04:00 2020-03-27T17:30:00-04:00
People leave after being tested for Covid-19 at Elmhurst Hospital Center in the Queens borough of New York City on March 26. Elmhurst reported the death of 13 Covid-19 patients in a 24-hour span on March 25. | AFP via Getty Images

“Rationing” — a form of decision-making to allocate scarce resources — is something health care providers hope they never have to do.

But already the Covid-19 pandemic has forced doctors and nurses around the world — in Italy, the UK, and South Korea — to ration lifesaving equipment and interventions: who gets a ventilator when there aren’t enough for every patient who needs one, for instance. And now, reports from overwhelmed and under-resourced hospitals across New York City’s five boroughs indicate that doctors and nurses there expect to begin rationing soon — if they haven’t already.

“These decisions run counter to everything that we stand for and are incredibly painful,” wrote Meredith Case, an internal medicine resident at Columbia/New York-Presbyterian Hospital, in a March 25 Twitter thread. “Our ICU is completely full with intubated Covid patients. … We are rapidly moving to expand capacity. We are nearly out of PPE. I anticipate we will begin rationing today.”

A worst-case scenario that epidemiologists have warned of — patients dying because the system is too overwhelmed to care for all of them — looms for New York City as a growing number of patients with severe cases of Covid-19 seek emergency medical care, and hospitals run low on ventilators. Hospitals are also running low on beds, intensive care units, personal protective equipment (PPE) to protect their frontline staff, and staff themselves. And after being ordered by the state to increase capacity by a minimum of 50 percent, hospitals are working rapidly to prepare for an even greater influx of patients in the coming weeks.

Because as bad as things are right now, they’re predicted to get worse. In a March 27 announcement, New York Gov. Andrew Cuomo said that the peak in the city’s epidemic curve —  when the number of Covid-19 cases top out before declining — could be as many as 21 days away. It’s based on the fact that people infected with Covid-19 can go for days before they show any symptoms and weeks before the most severe cases require hospitalization. 

There’s still uncertainty in how the outbreak will play out in New York, since it is impossible to know the number of residents who have already contracted the virus. Though the testing rate here is the highest in the country, the city still doesn’t have the capacity to test everyone with and without symptoms. But officials and medical professionals agree the official counts — as of March 27, there were more than 25,000 reported cases and more than 350 reported deaths in New York City — don’t reflect the true extent of the outbreak.

“The number of patients with severe enough illness to need hospitalization and ICU-level care is expected to rise faster than our ability to fully meet the demand,” wrote Vicki LoPachin, the chief medical officer at Mount Sinai Health System, in a letter to the hospital staff on March 25. “This is the humanitarian mission of our lifetimes. And we won’t win every battle.”

Hospitals are reaching capacity and workers on the frontlines are falling ill

With more than 4,700 Covid-19 related hospitalizations as of March 26 in New York City, about 850 of which have been intensive care unit hospitalizations, hospitals are in crisis mode. Many of them have been for days.

“Even for my senior attendings, it is the worst they have ever seen,” wrote Fred Milgram, an emergency medicine resident physician, in the Atlantic. “Here, the curve is not flat. We are overwhelmed.”

Nurses and doctors have been reusing masks and other personal protective equipment, or PPE meant for single-use since last week, and some health providers are continuing to care for patients even while they experience symptoms of their own. “I am ending my night by delivering acetaminophen to a co-resident who spiked her first fever today,” Case wrote in another tweet. “She is one of many in recent days.”

While New York City officials have not provided an official tally of how many health care providers have tested positive for Covid-19, data from other countries hit hardest by the pandemic, including Italy, reveal that providers are at a high risk of contracting the virus — especially in the absence of adequate PPE. 

“As I’ve sat in a room full of coughing patients for 60 hours a week, I have worried about my own safety,” wrote Rachel Sobolev, another of NYC’s emergency resident physicians, in a letter to President Trump published on HuffPost. 

On March 24, Kious Kelly, an assistant nurse manager at Mount Sinai West hospital died of Covid-19. According to social media posts from his family members and colleagues, the 48-year-old Kelly was otherwise healthy, but he had not had adequate PPE while caring for his Covid-19 patients.

Gov. Cuomo said in a press conference March 26 that there was “no question” that New York at large would exceed its hospital bed capacity. According to data from the Harvard Global Health Institute, the city has roughly 1,400 ICU beds total. For several hospitals in NYC, including Elmhurst Hospital in Queens, where 13 patients died of Covid-19 in 24 hours, this has already happened.

“I don’t think it’s a question of ‘when’ hospitals are out of space anymore,” says Ani Bilazarian, an ER nurse at one of New York City’s major trauma centers. “It’s happening now.”

The measures that NYC hospitals have taken to extend capacity and care for critically ill Covid-19 patients are extreme and unprecedented. Hospitals have begun to convert pediatric units into adult ICU rooms, transferring the children who previously occupied those rooms to other hospitals. Operation rooms previously reserved for surgery – left vacant in the wake of cancelled elective procedures – have also been converted to ICU rooms at many hospitals.

The equipment shortage is “becoming dire”

In addition to dwindling physical space and hospital beds, NYC’s hospitals are running dangerously low on critical equipment. “The shortages of resources is becoming dire even outside of the news reporting of ventilators,” says Bilazarian. “We are on critical shortages of multiple medications, protective equipment, cleaning products, and space.”

To intubate patients, hospitals need ventilators, the crucial machines that pump air into the lungs of patients unable to breathe properly on their own. In the face of a virus that attacks the respiratory system, these machines can be lifesaving. And yet, as of March 26, Cuomo said that New York had only about 12,000 ventilators total, just over a third of the projected 40,000 ventilators required to accommodate the inevitable increase of patients. 

A shortage of ventilators would be a dire situation in the face of any respiratory pandemic, but the drawn-out nature of Covid-19 illness exacerbates the problem.

“Non-Covid patients are on ventilators two, three, or four days,” Cuomo said in his March 27 press briefing. “Covid patients are on ventilators from 11-21 days.”

Bilazarian adds: “The challenge with ventilator resources is not just the high numbers of patients we are intubating but the length of time they are required to remain on a ventilator. We have been keeping patients on ventilators for about 14 days before we decrease ventilator support in a process called ‘weaning’.” 

In other words, patients with Covid-19 are staying hooked up to these scarce ventilators for long and indefinite periods. Accordingly, the equipment cannot be recirculated fast enough for use in newly-admitted patients.

Solutions are arising – but hospitals need more help now

New York City’s hospitals aren’t fighting Covid-19 alone; they are working alongside the state and local health departments and the private sector to address the shortage of space and resources. The Jacob J. Javits Center, a convention space on Manhattan’s west side, is being converted into a 1,000-bed temporary hospital. A 1,000-bed hospital ship, the USNS Comfort, is expected to begin admitting NYC patients in mid-April. Nationally, several manufacturers in the auto industry have converted to making ventilators, but the progress has not been adequate. 

In a tweet on March 27, President Trump said that General Motors, the automotive company that had previously promised to manufacture 40,000 ventilators “very fast,” has since backtracked, promising 6,000 ventilators by late April. 

New York City’s hospital systems need resources immediately and cannot wait for these national solutions; accordingly, several are taking matters into their own hands. 

Northwell Health, for example, the New York health care system with 23 hospitals, has begun 3D printing equipment to use machines that they already have in their own facilities as opposed to waiting on companies. Northwell Health has partnered with the 3D printer company Formlabs to expedite production of nasal swabs required for Covid-19 testing kits as well as 3D-printed nozzle-like devices that allow ventilator machines meant for single patients to be split between two patients. 

The 3D printed nasal swabs for the Covid-19 testing kits, which are modeled after swabs that already existed, have gotten the green light for production and are currently being dispersed throughout Northwell’s hospitals and testing centers.

But 3D printing ventilator splitters — which are essentially T- or Y-shaped nozzles that hook onto a single ventilator tube and redirect the oxygen flow from the ventilator into two tubes as opposed to one — is not quite so straightforward, because these designs are unchartered territory and need to be tested for safety and efficacy.  

“Splitting ventilators is really a last-ditch effort,” says Todd Goldstein, Northwell Health’s director of 3D design and innovation. “The ventilators are made for one individual patient, and even though it’s been done before, it’s complicated to split them. There are a lot of factors you have to control, and there are a lot of issues that can arise.”

Several other hospitals have already begun splitting ventilators between multiple patients. 

“We are also trying to be more flexible in how we support patients … to try and prevent patients from needing vents at all,” Bilazarian said of her hospital. In other words, hospitals are trying to use less invasive electronic breathing devices first (such as the mask-like BIPAP machines, which are sometimes used for people with sleep apnea) to stave off the need for full intubation.  

Expanding the frontlines

Nowhere does the wartime rhetoric of the Covid-19 pandemic seem starkest than in the draft-like call-to-action for volunteer health providers in New York. The state’s department of health has added a form on its website for any qualified health providers to join a volunteer reserve workforce. “We are looking for qualified health, mental health, and related professionals who are interested in supporting the state’s response,” the site reads. 

On March 24, New York University announced that it would allow fourth-year medical students to graduate early so as to join the frontlines of the Covid-19 response in New York City as soon as April. By March 25, nearly 70 medical students had decided to graduate early; they made the choice to enlist in the frontlines in spite of the risks.

If nothing else, New York’s health workers’ dedication to the work they’re doing — saving as many lives as they physically can — is clear in their remarkable reports from the front lines.

“We feel honored to continue serving our patients to the best of our abilities,” says Bilazarian. “This pandemic will require citizens to make real sacrifices. We need you to stay at home. But as our ER says, ‘we never close, we are always open, we are here for you.’”

]]> Caroline Hopkins <![CDATA[“We are desperate”: Trump’s inaction has created a crisis with protective medical gear]]> https://www.vox.com/2020/3/22/21189896/coronavirus-in-us-masks-n95-respirator-doctors-nurses-shortage-ppe 2020-03-23T14:30:41-04:00 2020-03-23T10:12:55-04:00
Single-use N95 masks like this one are in short supply for health workers and other first responders battling the Covid-19 pandemic. | Kent Nishimura/Los Angeles Times

A long foreseen shortage of personal protective equipment (PPE) — including masks, N95 respirators, and gowns — is crippling health workers’ ability to respond to the coronavirus pandemic in the United States. And as doctors and nurses are forced to reuse gear in ways that put themselves and patients at risk of infection, they’re begging the Trump administration to use readily available legal tools to solve the crisis.

In a joint March 21 letter to President Trump, the American Medical Association, the American Hospital Association, and the American Nurses Association called on the administration to “immediately use the Defense Production Act to increase the domestic production of medical supplies and equipment that hospitals, health, health systems, physicians, nurses and all front line providers so desperately need.”

The Defense Production Act of 1950, originally signed during the Korean War, gives the president the authority to demand that businesses manufacture much-needed wartime supplies. In this case, the supplies aren’t titanium artillery; they’re equipment to protect frontline health workers from a highly contagious virus. In using the DPA, the president would order “the diversion of certain materials and facilities from ordinary use to national defense purposes, when national defense needs cannot otherwise be satisfied in a timely fashion.” In other words, he would direct factories that typically make other goods to start making medical resources ASAP. 

Although Trump tweeted March 18 that he had signed the DPA, he said he would only be using it in a “worst case scenario in the future.”

And, when asked in a March 21 press briefing why he had not yet compelled companies to manufacture and sell supplies in accordance with the DPA, he said, “We have the Act to use in case we need it, but we have so many things being made right now by so many … they are volunteering.”

Yet the joint AHA-AMA-ANA letter makes it clear that current voluntary efforts are insufficient, and that the “worst case scenario” is already here.

“Even with the infusion of supplies from the strategic stockpile and other federal resources, there will not be enough medical supplies, including ventilators, to respond to the projected COVID-19 outbreak,” the letter reads. “We have heard of health care providers reusing masks or resorting to makeshift alternatives for masks.”

Interviews with doctors and nurses on the frontlines of the Covid-19 pandemic, many of whom requested anonymity because they did not have permission from their hospitals to speak with the media, show that there is no time for the confusion surrounding whether Trump actually plans to use the DPA.

The shortage is requiring health care officials to stretch their current supplies in creative — and dangerous — ways

Doctors, nurses, and hospital administrators have been warning that they might run out of PPE for weeks now, but the warnings have become more urgent in recent days. For many hospitals, running out of masks is no longer something that “might happen.” The shortage is here. 

Among the resources running dangerously low are N95 respirators, the masks that cup the face closely and have been approved by the National Institute for Occupational Safety and Health (NIOSH) to block the inhalation of 95 percent of small airborne particles. 

According to NIOSH guidance for extending N95 supply, hospitals should advise their staff to, “discard N95 respirators following close contact with, or exit from, the care area of any patient co-infected with an infectious disease requiring contact precautions.” But as the shortage worsens, reusing these masks is becoming the go-to method of preservation. 

“Initially, we had single-use N95 masks,” says one nurse who has been treating Covid-19 patients at Cape Cod Hospital in Hyannis, Massachusetts. “Now we reuse our N95s five times before discarding.” The eye shields she uses are also meant for single use, but nurses are being asked to wear the same eye shield for 12 hours. “We’re bringing them between different patient rooms, which isn’t exactly ideal,” she says. 

In cases where providers must reuse PPE such as N95s, the CDC recommends measures such as hand-washing before adjusting the masks and storing them in clean paper bags when not in use. 

The shortage of hospital masks, gowns, and eye shields poses a health risk to both providers and the patients they’re treating. Reusing masks or wearing the same eye shield when treating multiple patients further contributes to the spread of Covid-19 at a time when the country desperately needs to be slowing down the rate of new infections, or “flattening the curve.”

While it’s unclear exactly how many health providers in the US have been infected with Covid-19 so far specifically due to the reuse of PPE or for other reasons, Italy’s experience is telling. Equipment shortages have also been dire there, and over 4,000 health care workers have been infected and over a dozen have died. Over 3,000 health workers in China were infected as well, with several deaths.

In the US, the shortage is affecting small clinics and large, well-funded hospitals alike.

The nurse from Cape Cod Hospital, who shared that she and her colleagues had been reusing N95s, said, “We are one of the more fortunate hospitals right now. We have definitely not peaked in this area yet, [but] it’s only a matter of time before we run out of masks. We definitely need more.”

Ani Bilazarian, 25, an ER nurse at a New York City trauma center, says the protocol at her hospital is “truly changing every hour of every day in terms of what we’re wearing.” She says the original protective protocol for nurses at her hospital included wearing an N95 mask layered beneath another mask, layered beneath a disposable face shield, which was to be discarded after treating each patient. “Now it’s definitely getting more drastic, even just within the week,” she says. “We got an email yesterday saying we have one mask to keep for our entire shift, and that we should bring it home with us … that’s our one mask. For I’m not sure how long.”

To avoid having to reuse N95 masks, many hospitals are allocating them only to staff members who are directly entering patient rooms — which, in turn, means limiting the number of staff members who enter patient rooms in the first place. 

“Before, if I forgot a medication or had to leave a patient’s room, I would have to take off [all of my PPE] and put it all back on,” says Bilazarian. “But we’re trying to combat that with innovative solutions. We now have people outside the rooms — we’re calling them runners — who can go get you stuff. So we’re definitely trying to limit the number of people requiring PPE and who need to be exposed at all.”

A spokesperson from the Boston Medical Center said his hospital is taking similar measures. “We’re limiting the number of staff that go into patient rooms and the number of times we enter and exit to preserve supply [of PPE],” he said. “We’re looking closely at alternate sources of supplies like construction shields, and thinking creatively to clean, disinfect, and reuse equipment to preserve supply.”

Other hospitals are limiting the use of N95s at all, turning instead to less protective options.

”The management is telling the nurses to wear masks that are not N95, even though most of us would feel more comfortable and safer with the N95,” says another nurse, who works at Baptist Health in Miami. “We are trying to fight for what’s right but when the CDC says you can wear a bandana or scarf in the place of a mask, it’s hard,” referring to the CDC’s guidance for optimizing the supply of facemasks. It notes, “In settings where facemasks are not available, HCP might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort.”

Some states are requiring dentists and veterinary clinics to donate surplus PPE to hospitals

While health care workers are working to stretch their own supplies, some local officials are rallying other industries that use PPE to funnel it to local hospitals and clinics.

Oregon Gov. Kate Brown signed an executive order requiring all hospitals, ambulatory surgery centers, outpatient clinics, dental clinics, and veterinary clinics with surplus PPE supplies to notify the state’s PPE coordinator to arrange for a handoff. Vets, dentists, and the like are ordered, by law, to participate in the reallocation of this excess equipment to the nurses and doctors directly treating patients. According to the executive order, any person found to be in violation would be subject to the penalties of a Class C misdemeanor.

As for industries that use PPE in other capacities, like construction and farming, the Oregon executive order “strongly encourages” — though does not mandate — that these individuals and entities “cancel or postpone non-essential uses of PPE during the ongoing state of emergency, so that the equipment can be conserved and redirected to the state’s Covid-19 response.”

For the federal government’s part, Vice President Mike Pence has said that “industrial masks that they use on construction sites are perfectly acceptable for health care workers to be protected from a respiratory disease,” and is urging construction companies to donate their supply of N95s. The Families First Coronavirus Response Act, which President Trump signed into law March 19, includes protections for industries manufacturing personal respiratory protective devices — meaning that the government will protect these companies from lawsuits if they sell the masks to health workers. 

But as the AHA-AMA-ANA letter to Trump noted, protecting these companies from lawsuits is not enough — the government, they say, must use the DPA to directly order them to manufacture these supplies. 

“We need companies to be creative”

As the PPE shortage continues to affect more of our nation’s hospitals — and the DPA-ordered manufacturing remains in limbo — public officials like New York Gov. Andrew Cuomo are also calling on individuals and companies to generate unconventional solutions.

In its guidance, the CDC says that “homemade masks are not considered PPE, since their capability to protect HCP is unknown,” and suggests that “homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face.”

The homemade option is nonetheless listed as a last resort — and one that many hospitals are exploring. 

Take for example, Dr. Mark Lewis, a hematologist and oncologist at Intermountain Healthcare in Utah, who shared a step-by-step sewing tutorial on Twitter:

Bilazarian, the New York trauma nurse, says she is grateful for the creative DIY solutions people are coming up with, but has doubts about whether they will be effective enough to protect providers like herself and the patients they’re caring for.

“We have about 15 nurses out now from the ER, and more professionals are getting sick,” she says. “For now, we are managing with the resources that we have, but we are increasingly concerned for staffing and physical resources — not just PPE, but also ventilators, fluids, and pain medication as the virus intensifies, especially here in New York. We have to ask, ‘Is our frontline staff prepared to fill in the gaps in care when we need them?’ I hope so, but I’m not quite sure at this moment in time.” 

To safely and adequately protect providers and patients as the pandemic inevitably spreads further, large-scale PPE manufacturing efforts are needed to resupply hospitals with the safest gear. But doing so — and then distributing the gear— could take days and weeks that nurses and doctors don’t have to spare. 

“We are desperate,” said another nurse who works at a New York hospital, who said she had spent her one day off running around collecting donations for PPE. “Please urge anybody who can donate any masks, but most importantly N95s, to do so.”

Caroline Hopkins is a Brooklyn-based health and science reporter. She has written for National Geographic, the American Society of Clinical Oncology (ASCO) Daily News, SurvivorNet, and Women’s Health Magazine. She has a master’s degree in journalism from Columbia University and can be found on Twitter at @Ch_Hops.

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]]> Caroline Hopkins <![CDATA[The dilemmas facing cancer doctors and patients in the coronavirus pandemic]]> https://www.vox.com/2020/3/20/21186681/coronavirus-cancer-treatment 2020-03-20T18:21:36-04:00 2020-03-20T07:30:00-04:00
Silver Leo with her 3-year-old son. | Courtesy of Silver Leo

Silver Leo has been trying to keep her young children, ages 3 and 9, entertained at home since March 13, when their public schools in Alexandria, Virginia, announced closures. Child care is a challenge for a lot of parents these days, but particularly for Leo. She has metastatic breast cancer, and the lingering effects of her weekly chemotherapy infusions make it difficult to stay high-energy — and risky to leave the house.

“Some of their friends are still having playdates, and doing this sort of ‘small group social isolation’ thing” says Leo, 40. “I have to explain to them that their mom has cancer, so they can’t have any playdates at all.”

Leo cannot even risk allowing anyone in her immediate family, including her husband, to go to the grocery store right now.

There’s a troubling amount we still don’t know about the novel coronavirus and the disease it causes, Covid-19. One thing we can say for certain is that the disease poses a far greater health risk to those with compromised immune systems, including cancer patients in treatment. For them, Covid-19 can be much more severe and more likely to be fatal. This isn’t up for debate; it’s a resounding warning, and one that the Centers for Disease Control and Prevention highlights as a case for widespread social distancing.

There are limited data on Covid-19 outcomes among the immunocompromised, but according to a special March 17 preprint report from the National Comprehensive Cancer Network, early reports out of China show that patients with cancer infected with Covid-19 have a 3.5 times higher chance of mechanical ventilation, ICU admission, or death compared with patients without cancer.

It’s a major concern, given there are about 650,000 patients with cancer who receive chemotherapy in the United States each year.

Cancer doctors face a “particular predicament”

Given that the virus is spreading in the US, the question about whether to continue immune system-suppressing cancer treatments during the Covid-19 pandemic appears to have no clear cut answers. 

“Oncologists are in a very particular predicament right now,” says Dr. Siddhartha Mukherjee, a hematologist and oncologist at Columbia University Medical Center and Pulitzer Prize-winning author of The Emperor of All Maladies. “Because on the one hand, you don’t want to delay treatment, but you also don’t want to expose patients to risk.”

There are about 650,000 patients with cancer who receive chemotherapy in the United States each year

“I’m very worried about my patients,” says Dr. Narjust Duma, an oncologist at University of Wisconsin Carbone Cancer Center who treats patients with advanced lung cancer. “Even with regular influenza, my patients could get very sick. But these treatments are keeping them alive.”

Chemotherapy does to cells what the coronavirus pandemic is doing to the population: It goes after everyone.

Although chemo drugs vary in terms of their effects on immune function, the risks of the treatment damaging healthy white blood cells — the body’s best defense against viruses — can become life-threatening.

Oncologists like Duma are acutely aware of the risks of their immunocompromised patients contracting Covid-19. But they’re also aware that stopping or canceling chemo, for many patients, could present more certain dangers.

Flattening the curve — and managing cancer care

Under normal circumstances, oncologists usually give patients undergoing chemo a list of recommendations that echo the advice we’ve all been hearing for weeks: wash your hands as often as possible, stay away from crowds, dine at home, don’t touch your face, don’t shake hands.

But these are not normal circumstances. Oncologists and patients are seeking further guidance, and that guidance isn’t one-size-fits-all.

“Patients have no choice but to take the Covid pandemic into account in their treatment decisions,” says Dr. Noel Brewer, a researcher in health behavior at the University of North Carolina Gillings School of Global Public Health. “It is no longer optional.”

The American Society of Clinical Oncology (ASCO) has put out a series of FAQs for the more-than 45,000 oncologists who defer to them for practice guidelines. But the organization has written that, “At this time, no specific recommendations can be made … for delay in therapy or choosing alternate therapy in the context of Covid-19 infection.”

Accordingly, oncologists, nurses, care teams, and hospital administrators have been working to address each patient individually.

Individual treatment decisions should consider factors such as the stage of the cancer, the specific type of chemotherapy they’re receiving, and the risk of cancer recurrence if treatment should be delayed, ASCO says. There is currently no evidence to suggest a benefit to delaying chemo in light of Covid-19 risks, the group says, although there may be cases in which adjuvant chemotherapy, meaning chemotherapy that’s given in combination with another type of treatment, such as surgery or radiation, may be appropriate to delay.

Dr. Marc Lippman, a researcher and breast cancer oncologist at Georgetown University Medical Center, argues that, at least in the context of breast cancer, treatment delays aren’t appropriate. “Delaying chemotherapy out of a fear of coronavirus is a total misunderstanding of risks and gains,” he says. “We know from a lot of studies that if you delay the administration of chemo, it’s less effective. Chemotherapy should not be delayed. Far more women will be harmed than possibly disadvantaged by the risk of the virus in my view.” 

Having practiced oncology for decades, Lippman’s assessment stems from his view that the drugs typically used to treat breast cancer in the adjuvant setting aren’t known to be as immunosuppressive as, say, some of the regimens used to treat leukemia or lymphoma.

“But, obviously, it’s still their choice,” Lippman says of his patients. 

As of this past weekend, one of Lippman’s patients, a 36-year-old woman with breast cancer who requested her name not be used to protect her privacy, had made her own decision to skip her chemotherapy infusion on Wednesday. 

“I thought of all the different places I would have to touch getting from my house to the clinic,” she says. “The doors, the elevators …”

“We know what would happen if we delayed”

As Covid-19 continues to spread, hospitals are taking drastic measures to care for those who have already been infected with the virus and to protect, at great costs, those who have not. For many hospitals and clinics, including Columbia’s Irving Cancer Center where Mukherjee treats patients, this has meant canceling elective surgeries, postponing routine visits, and requesting that non-urgent patients consider telehealth for their appointments.

For many patients with advanced cancer, though, hospital visits are far from elective and most certainly not “non-urgent.”

Postponing elective surgeries and follow-up appointments should be fairly straightforward decisions, according to the National Comprehensive Cancer Network special report, which lays out guidance for hospital staff to prepare for the coming weeks and months. The more difficult decisions, it reads, are “clinical decisions regarding delay of treatment for patients who are currently undergoing chemotherapy or about to begin.”

“We have a commitment to treat patients as per their normal protocols and not delay any treatments that are required,” Mukherjee says. “This is a time for patients to work closely with their oncologists and then figure out how to appropriately manage their care.”

On March 13 — the day when President Trump officially declared the Covid-19 pandemic a national emergency — Duma met with a patient who had just been diagnosed with advanced small-cell lung cancer, the most aggressive type of lung cancer. “We need to get going on his treatment right away,” Duma says. The patient was already coughing up blood and would continue to do so unless he was treated. “We know what would happen if we delayed.”

What months of social distancing could mean for cancer patients

The biggest deterrent, perhaps, to postponing chemo due to Covid-19 risks is that we just don’t know how long this pandemic, and the response to it, could last. Many patients are okay skipping one or two chemo doses, but if a patient were to delay their chemo treatment right now, it might not be any safer to resume the treatment should they reschedule it for the coming weeks or months. 

“This is a dynamic situation,” Mukherjee says. “It might change. But right now, at least in my practice, we haven’t had to make those sort of, you know, terrible bargains thus far.”

For Jamie Hecker, a 54-year-old man with a bone marrow cancer called myelofibrosis, the potentially months-long duration of the pandemic poses a far more serious set of concerns than does skipping a dose or two of his chemo. 

Right now, Hecker’s chemo is working well. For about a year, he’s been receiving four injections of the drug Vidaza (azacitidine) in his abdomen for seven days in a row once a month. But if the chemo stops working — which is common after a year or two on the drug, according to Hecker’s oncologist — Hecker would have to turn to his only other available treatment option, a bone marrow transplant. 

The transplant would temporarily wipe out Hecker’s immune system, making it one of the riskiest treatments a patient could receive during a global pandemic. This is why, given the risks of Covid-19, ASCO, and the American Society for Transplantation and Cellular Therapy list these transplants as unique cases for which deferrals may, in some cases, be appropriate.

The question of the pandemic’s duration has been especially difficult for Leo in Alexandria, who has already been told she has just three to five years to live. Every treatment and chemo infusion is factored into that life expectancy. 

“With terminal cancer, there’s this sense of time,” she says. “Vacations matter. Being with family and friends matters. Now vacations are all postponed, my elderly parents can’t fly, and I can no longer see my friends because they decided to expose themselves by going to brunch … when you’re not sure how much time you have left, isolation means something different.”

For now, Leo is still going in for her chemotherapy infusions, because, as she says, “cancer doesn’t care about coronavirus.” The malignant cells will continue to spread, social distancing or no social distancing. 

What if patients on chemo test positive for Covid-19?

When asked how he would proceed if one of his patients receiving chemotherapy were to test positive for Covid-19, Mukherjee said, “What we would do would be to follow the guidelines for giving chemotherapy in the context of an infection — any infection, Covid or otherwise — which is to wait until the infection is resolved to resume chemotherapy.”

Of course, following these protocols would require more Covid-19 testing kits, which are not currently available in every clinical setting. If there were not a test-kit shortage, doctors would be able to test every patient prior to beginning chemotherapy, symptoms or no symptoms, to determine if they have the virus before compromising their immune systems with chemotherapy. This could be worth considering because the virus has been shown to have roughly a five-day incubation period, meaning symptoms could be delayed.

“Many of our patients who are immunocompromised might show up with tests that are positive, but have no clinical manifestations of disease,” Mukherjee says. “And there are no guidelines for this. This is where we are practicing the art of medicine.”

As more information on this virus becomes available, the hope is that these decisions will become less of an art and more of a science again.

But for now, patients with cancer are living in a state of uncertainty — a state that, for many of them, is already familiar. 

While her treatment has left her less equipped to fight off Covid-19 should she get it, Leo believes the whole cancer experience, somehow, has left her better prepared to handle the pandemic mentally.

“I believe something good will come out of this,” she says. “And believing something good will come out of it is a muscle … it’s something you train yourself into.”

Leo has been training that muscle ever since her terminal diagnosis.

“That ‘something good,’ I hope, is that we will come together as a society. That once after everyone is done with brunch and grandma dies, maybe we can become more aware of what life is about … that it’s not always about distraction and entertainment, but real connection.”

Caroline Hopkins is a Brooklyn-based health and science reporter. She has written for National Geographic, the American Society of Clinical Oncology (ASCO) Daily News, SurvivorNet, and Women’s Health Magazine. She has a master’s degree in journalism from Columbia University. 

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