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During COVID-19, Cancer Surgeons Find “Bridges” to Care for Patients

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Meredith Cleary received a clean bill of health for every one of the last three uterine surgeries that she has needed to address abnormal bleeding. But this year, of all years, turned out differently. During the surgery at a suburban hospital in early March, her doctor found endometrial cancer, a common type of uterine cancer that starts in the inner lining of the uterus.

Under normal circumstances, Cleary would have gone in for a follow-up visit to talk through the results from her doctor, but because of COVID-19, she had to limit her exposure to other people. The Center City Philadelphia resident was caring for her 90-year-old mother and 91-year-old aunt down in Sea Isle City, N.J., and needed to keep them safe.

“[The doctor said] she understood and then told me, ‘I hate to give this kind of news over the phone, but we did find cancer,’” Cleary said. “I really wasn’t expecting it to be much, but it turns out it was.”

With her doctor retiring, Cleary decided to find someone in Philadelphia, so she connected with the division of Gynecologic Oncology at Penn Medicine, where 68-year-old Cleary learned what her options during a pandemic would be. The most common treatment for endometrial cancer is a hysterectomy, but cases of COVID-19 were surging during this time, so most surgeries were being delayed to ensure capacity to care for patients with the virus. She would have to wait. 

Thankfully, she and other patients with gynecological cancers had options — bridges to surgeries that would allow them to safely wait until the situation improved. For Cleary, a hormone therapy known as progesterone was that bridge.

Ashley F. Haggerty, MD, MSCE, an assistant professor of Obstetrics and Gynecology and gynecologic oncology surgeon, turned to science to manage patients like Cleary. Studies from Penn’s clinical research group conducted within the last few years showed that delaying surgeries for up to eight weeks was safe and didn’t significantly impact outcomes. Other data also proved that hormone therapy is effective for women when surgery isn’t an option, particularly younger women who haven’t had children yet and choose not to pursue a hysterectomy.

“I think having all that data to extrapolate to a different patient population, at least as a bridge to get through that time, was really helpful,” Haggerty said.

In late March, Cleary, still self-quarantining near the New Jersey shore, began taking progesterone, two pills a day that left her with little to no side effects.

“I really wasn’t upset about it until it went like three more weeks,” she said. “Then I just kept thinking, ‘I just want this thing out of me.’”

Cleary lost her husband to bile duct cancer five years ago this month and has watched others close to her battle cancer. “I have seen how devasting it can be,” she said.

In all, 62 women treated in the division of Gyn/Onc at the Abramson Cancer Center — which included patients at the Hospital of the University of Pennsylvania, Pennsylvania Hospital, and Chester County Hospital — would have their surgeries rescheduled because of COVID-19. Ensuring that these patients received close monitoring and a smooth pathway to getting this needed care was a top priority for Penn Medicine clinicians during the pandemic.

Working with a group from the Penn Institute for Biomedical Informatics led by Peter E. Gabriel, MD, an associate professor of Clinical Radiation Oncology, Gyn/Onc clinical leaders built a list to ensure no patient fell through the cracks. Everyone being treated for Gyn/Onc cancers was tracked and prioritized for surgeries once they could resume — and in many cases provided with various other bridges of care until then.

That list included women with ovarian cancer. For them, pre-surgery chemotherapy, known as neoadjuvant, has been shown to be a viable option. Three to four cycles of therapy prior to surgery doesn’t appear to significantly affect outcomes, according to research, which gives them an additional nine to 12 weeks before they need to have their procedures, Haggerty said.

Patients had to come to the hospitals to receive chemotherapy, but the teams worked to streamline that care through telemedicine pre- and post-infusion calls, by seeing patients directly in the infusion suites, and by keeping them in one location, even for laboratory blood tests, to reduce movement around the hospital and their risk.

“We really adapted to see the patients where they were,” Haggerty said.

Telemedicine has played a critical role in care as health systems around the country hit the pause button on many outpatient and inpatient services due to the virus. Penn’s division of Gyn/Onc conducted a large swath of visits via telemedicine for follow-up counseling sessions to discuss imaging, for example, or next steps that didn’t require an exam.

In at least one instance, telemedicine served as a bridge to future care. Emergency room physicians at Penn referred a woman who visited the ER for bleeding to Haggerty, but because of certain social situations she missed two appointments. Eventually, Haggerty and the patient were able to connect, thanks to telemedicine, where a colonoscopy and imaging could be scheduled to properly access her condition and potentially save her life.

“I felt like that was a really remarkable patient encounter to show another role that telemedicine has played during all this,” Haggerty said. “I see it continuing for us beyond this.”

Because not all surgeries can wait, Haggerty and the Gyn/Onc team did perform procedures on anywhere from two to four cancer patients each week who were more acutely ill, using COVID-19 safety protocols, like universal masking, pre-admission testing, and programs to facilitate earlier discharges home from the hospital.

By early May, regular surgeries started up again at 50 percent capacity, which increased to 75 percent a few weeks later, and 100 percent by the first week of June. Cleary had her surgery on May 15 and was admitted and discharged all in one day — another change for the better that became more widespread during COVID-19 and Haggerty sees continuing on.

“You wouldn’t have noticed that it was [a pandemic],” Cleary said. “There wasn’t anything that made me feel rushed, hurried, or unsafe. Everything just went so smoothly.”

The surgery was a success. Six days later, Haggerty called Cleary to discuss the pathology report. They removed one small tumor in her uterus, and the cancer hadn’t spread to her lymph nodes.

“I couldn’t have asked for a better outcome,” Cleary said. “Someone said to me the other day, ‘You realize now that you’re a survivor.’ But I feel like a cheat because we caught it so early. I just wish everyone could have it as easy as I did.”

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