Nicole Laferriere is the Medical Director and Chief of Oncology at the Thunder Bay Regional Health Sciences Centre, Regional Cancer Care Northwest
Gwynivere Davies is a hematologist at Thunder Bay Regional Health Sciences Centre, Regional Cancer Care Northwest
Recently one of us diagnosed a patient with a type of leukemia that usually requires hospitalization for a month because of the type of treatment required. These patients need transfusions of blood products, frequently develop infections and sometimes require intensive care.
We shared this grave diagnosis and treatment plan with our patient, and while he digested the news, we called intensive care. “If our patient gets sick, can he still go to the ICU?” Their reply: “For now indications are the same, but it’s hard to say where we’ll be in a month.” A recent study from Wuhan showed that around 30% of patients with cancer who were in hospital with COVID-19 died, compared to less than 3% of patients without cancer. Additionally, some guidance suggests that individuals with severe comorbidities (like cancer) may not benefit from intensive interventions compared to other patients with COVID.
Working in an isolated tertiary care center routinely presents logistical and ethical challenges. We expect these to increase during this pandemic.
As hematologists in Thunder Bay, which is a 17 hour drive from our provincial referral centres of Toronto and Ottawa, we routinely face challenges when delivering care. We serve an immense area (“the size of France”), with many communities only accessible by air or seasonally. Obtaining biopsies and accessing specialized investigations and treatments requires extensive coordination. We use air medical transport for communities without nurses, doctors or laboratory capacity and commercial flights to Sudbury or Toronto to transport bone marrow biopsy samples for special testing; we ship the isotope needed to run our PET scanner from Hamilton; we fly patients to other centers for stem cell transplantation; and we use taxis to transport platelets to Kenora. The list goes on.
Our intimate connection to personnel and resources in the rest of Ontario has become more apparent during this crisis. Reduced commercial flights due to COVID have led to rationing or delays in staging scans and biopsy samples waiting for transfer (which can affect sample quality). We are also considering transferring patients with cancer to other centres using expensive medical transport rather than commercial flights because their risk of exposure to SARS-Co-V-2 is greater on a commercial flight. Our hospital also uses many physicians from outside Thunder Bay who work here a few days to weeks at a time. Many of our specialty areas comprise only one to two physicians. The need to restrict travel of medical personnel is a necessary but challenging hurdle to overcome, especially given expectations of 25-50% staff shortages due to illness or quarantine.
There are other unique aspects to our geography that affect the health care we provide. With the closest Canadian Blood Services facility eight hours away in Winnipeg, blood components are either imported across the provincial border by courier or flown from southern Ontario. Though red blood cells can be frozen, platelets must be stored at room temperature and only last up to seven days, even shorter with irradiation. With mandated social distancing, it’s possible that fewer Canadians will donate. Therefore, we have pre-emptively lowered our transfusion thresholds, reduced the number of units transfused and are considering other supportive therapies such as tranexamic acid in case we exhaust our supply.
Around 13% of the population of Thunder Bay identify as Indigenous, compared to 3% in Ontario, and our region has many isolated Indigenous communities as far north as Fort Severn on the edge of Hudson’s Bay. In addition to transportation concerns, some of these communities lack running water and basic medications, have crowded housing that prevent physical distancing and, in the case of dry reserves, no access to hand sanitizer. Therefore, we ask ourselves if it is ethical to give immunosuppressing chemotherapy if patients must receive treatment in Thunder Bay and cannot return home due to lack of appropriate sanitation or travel restrictions. Are we actually increasing risk by forcing them to stay in alternate housing with non-oncology patients to receive care?
We are trying. We have examined our workflow to recognize these limitations and are developing creative solutions to address them. To adjust to reduced access to referral centres and specialists, we have changed the timing of laboratory shifts, coordinated with our receiving centres to reduce delays in transfer of biopsy samples and are working to quality-assure our nearly completed Cyclotron so that it can manufacture isotope. With a limited network of nurses providing home-care treatments after chemotherapy (e.g. filgrastim and hydration), nurses are proactively teaching patients and families to perform injections and care in case of quarantine. Our Indigenous navigator has liaised with the Health Unit to provide education regarding the importance of distancing, hygiene and maintaining quarantine for those patients displaying symptoms or who are swabbed. We have also asked drug companies for oral chemotherapies to replace treatments that require cancer center trips, reducing the number of healthcare encounters. We are hopeful that these changes will positively impact delivery of care when the initial crisis of the pandemic is over.
Our geographic isolation has led to a delay in COVID-19 cases compared to southern Ontario, allowing time for more planning, although the numbers are now rising. Recognizing these challenges, can centres like ours continue to provide high quality, efficient cancer care? It’s hard to say where we’ll be in a month. Our centre has always worked towards providing complex patient-centred care close to home. This is more imperative now than ever and remains the central focus of our dedicated team.
With these assurances, our patient decided to proceed with treatment, hoping for the best while preparing for the worst.