COVID-19 has no doubt changed many facets of laboratory medicine. But not a lot of people have talked about exactly how cancer management and workflows have changed. Are these changes permanent? Are they temporary? Many of us may not know for sure yet. So, we decided to spend some time and ask physicians what they think about changes they experienced. In this series, Scoping COVID-19, we are sharing these stories with you. So many of us have shared similar challenges and many have found creative solutions to adapt to new workflows. It is our hope that this series shares the collective learning experience about navigating the pandemic and strategies about how to move forward. Be sure to read part one of this series about a pathology resident on the frontlines of COVID-19.
One common thread amongst the pathologists we interviewed was the dip in case volume when elective surgeries were cancelled due to the COVID-19 outbreak. We talked with many pathologists, interventional radiologists and oncologists who provided us with a unique look into their day-to-day during peak coronavirus months and during hospitals reopening. These dialogues offer valuable insight on how the medical community can move forward facing these challenges together.
Dr. Yvelisse Suarez, a GI pathologist at NYU Langone Medical Center, told us, “Volume here dramatically decreased. The volume was limited to appendices and gall bladders and some emergency liver biopsies and medical biopsies that needed to be done. But we could count on our hands how many biopsies we had in a day. We went from 150 biopsies per day to less than 10 per day.” Dr. Michael Arnold, Medical Director of Anatomic Pathology at Children’s Hospital Colorado, also saw a big dip in biopsy volume. “Before COVID-19 we were at 650-700 surgical specimens each month. This was reduced to about one-third,” he explained. Dr. Raj Singh, Director of Dermatopathology and Associate Chair of Digital Pathology at Northwell Health in New York utilizes digital pathology for secondary consultations with pathologists from all over the globe. “Pre-COVID-19, almost every day I was getting consult requests from international colleagues. That went down almost 90%,” he told us. In addition, case volume in his department went down from 200-300 skin biopsies per day to around 10 skin biopsies per day.
Not all specialties involved in cancer management experienced reduced case volume. We talked with one interventional radiologist who had some of the highest volume when pathologists were seeing dips in cases. “Our volume went up because a lot of our work is not delayable. We also did procedures like placing gastrostomy tubes in patients when GIs and surgeons were unavailable to do it. Surgeons were utilizing interventional radiology to temporize COVID-19 patients; we would tube them until they recovered from coronavirus and were well enough for surgery. April and May were the most productive months of the year. I worked a similar number of hours but we all went to a staggered system--7 days on and 7 days off,” explained Dr. Thor Johnson, Associate Professor and Director of Vascular and Interventional Radiology Research at the Medical University of South Carolina. For other interventional radiologists, the volume did not have a big fluctuation; they just shifted how they treated patients. Dr. Mike Devane, Director of Interventional Radiology at Prisma Health Upstate and Associate Professor at University of South Carolina School of Medicine Greenville, told us, “The first major change we experienced was moving all of our outpatient visits to telehealth. Now we are offering a choice between virtual or in-office visits. We started seeing about 5% of our patients back in the office with 95% still participating in virtual visits.”
For pathologists, one major concern with the dip in volume was the decrease in patients getting treated. Dr. Genevieve Crane, a hematopathologist at Cleveland Clinic who was at Weill Cornell/New York Presbyterian in Manhattan when the coronavirus pandemic began explained, “As volumes dropped down dramatically, our concern was that people with illnesses such as acute leukemia were not getting seen at the hospital and that others with known hematologic disorders were forced to delay necessary follow-up because of coronavirus.” Dr. Sakti Chakrabarti, an oncologist at Medical College of Wisconsin, saw the effects of delayed treatment. “We’ve noticed we are seeing people presenting with later stages of cancer. Once they finally come to the ER, the cancer has progressed,” he told us.
The halting of elective procedures and significant decrease in case volume left many hospitals struggling to meet their budgets. We talked with numerous pathologists whose institutions had staff furloughs, employee cuts and hiring freezes in addition to pathologists experiencing reduction in their salaries. With elective surgeries back on the books, volume has increased leaving some pathology departments busier than ever while others still haven’t reached their pre-coronavirus volume. Dr. Jaclyn Rudzinski, a pathologist at Texas Health Presbyterian Hospital Dallas, said, “Our new normal as of early August seems to be the same mix of cases overall but slightly fewer of them. We are at about 90% of where we were this time last year.” Dr. Julie Feldstein, a hematopathologist at Mount Sinai, told us her department is at about 95% pre-coronavirus volume. “When the reopening of New York City started, our volume went up. Now it might be higher volume than it was pre-COVID-19. Biopsies are just as heavy as they used to be, if not more. We are extremely busy. The OR is extremely busy. With people not able to travel or enjoy their summer vacations and physicians trying to make up for lost business, operations are in full swing,” Dr. Suarez told us.
The issue of volume wasn’t just for cases; it was for colleagues, too. The number of staff working on-site evolved into working from home. For those who had to be on-site, there was the creation of mini-teams to ensure one cohort would be healthy should the other happen to have physicians fall ill to coronavirus. Dr. Rifat Mannan, Assistant Professor of Clinical Pathology and Laboratory Medicine at the University of Pennsylvania’s Perelman School of Medicine, explained, “Since the middle of March there have been changes. We have been very strict. The faculty got divided into two teams, one week on and one week off; the same with residents. Our main goal was to reduce the chance of more people at work at the same time. We did this for the whole months of March, April and May.” One physician who had the opportunity to work from home chose to come into the office. Dr. Eileen McKay, Division Chief of Community Pathology and Medical Director at Texas Children’s Hospital The Woodlands, told us, “As medical director of the lab I felt like it was best to be there in solidarity with my staff and to prevent any delays in happening from patients who needed our care. Our entire institution looked at different ways to keep staff as safe as possible. The support of the larger institution and working together within teams were key.”
From drastic decreases in case volume and minimal staff on-site to the return of cases and colleagues, the pathology landscape has looked quite different over the past several months. Tumor boards, conferences and team meetings have mostly been moved to virtual settings. We wonder if this is a trend that will be applied to other elements of cancer management in the long term, especially as we all become more proficient at operating remotely. For Dr. Liza Quintana, a breast pathologist and cytopathologist at Beth Israel Deaconess Medical Center in Massachusetts, believes this is a good thing. “Our residency director is always sending out emails with pictures on how to use different technologies. We are constantly getting better, and a lot of conferences and small meetings we have opened up to residents so they can Zoom in to different sessions. They are able to see a lot more,” she told us. Medical student and resident education has become increasingly virtual and increasingly inclusive, adding unique opportunities to excel in the learning arena at any stage in one’s medical career, from student to practicing physician. Stay tuned because we’ve dedicated part three of Scoping COVID-19 to learning amidst the pandemic. To new normals like social distancing and the return of case volumes, to challenges that put physicians in the face of COVID-19, what we know for sure is physicians from all specialties in cancer management are working in unison to serve patients and their families while remaining safe amidst this public health crisis.
We give a heartfelt thank you to all of the pathologists, oncologists and interventional radiologists we spoke with who openly shared their coronavirus experiences. Stay tuned for part three of Scoping COVID-19 where we cover the silver lining of coronavirus -- increased remote education and online pathology learning resources.
Built on the vision of better patient outcomes, Instapath was founded in 2017 by engineers and scientists to enable patients to immediately know their cancer diagnosis. Our team made it our mission to develop fast and easy digital pathology technology so diagnosis can be made in minutes instead of days. To learn more about Instapath and our technology, visit https://instapathbio.com/tech/ or contact us at email@example.com.