The impact of COVID-19 on cancer care and oncology clinical research: an experts' perspective

Viral Load Suppression in People Living with HIV Before and During the COVID-19 Pandemic in Brooklyn, New York

Consistent care is crucial for the health maintenance of people living with human immunodeficiency virus (HIV) (PWH). The coronavirus 2019 (COVID-19) epidemic disrupted patient care in New York City (NYC), yet few studies investigated the association between COVID-19 and viral load suppression in PWH in NYC. This study aims to assess how the COVID-19 pandemic impacted HIV viral load and CD4 + T-cell counts in PWH. Medical records of 1130 adult HIV patients who visited the Special Treatment and Research Health Center in Brooklyn, NY, between January 2019 and May 2023 were compared across three timeframes (pre-pandemic, January 1, 2019 to December 31, 2019; first pandemic phase, March 19, 2020 to December 31, 2020; and second pandemic phase, January 1, 2021 to May 11, 2023). Demographic and clinical variables (e.g. viral load and CD4 + T cell count) were assessed. About 40% of patients did not have routine laboratory monitoring during the first pandemic phase compared with pre-pandemic. The mean HIV viral load was higher during the second pandemic phase compared with pre-pandemic (p = 0.009). The percentages of patients with undetectable HIV viral load and numbers (mm3) of CD4 + T-cells were similar for all time periods. These findings indicate that the COVID-19 pandemic may have exacerbated challenges for individuals who already had barriers to medication adherence or access. However, most individuals remained consistently on their antiretrovirals throughout the pandemic. Further studies are warranted to determine how to mitigate the impact of future pandemics for the health of PWH.

What Is Ailing Oncology Clinical Trials? Can We Fix Them?

Evidence from phase three clinical trials helps shape clinical practice. However, a very small minority of patients with cancer participate in clinical trials and many trials are not completed on time due to slow accrual. Issues with restrictive eligibility criteria can severely limit the patients who can access trials, without any convincing evidence that these restrictions impact patient safety. Similarly, regulatory, organizational, and institutional hurdles can delay trial activation, ultimately making some studies irrelevant. Additional issues during trial conduct (e.g., mandatory in-person visits, central confirmation of standard biomarkers, and inflexible drug dosage modification) contribute to making trials non-patient-centric. These real-life observations from experienced clinical trialists can seem nonsensical to investigators and patients alike, who are trying to bring effective drugs to patients with cancer. In this review, we delve into these issues in detail, and discuss potential solutions to make clinical trials more accessible to patients.

A call to action to advance patient-focused and decentralized clinical trials

This commentary is a call to action for a concerted commitment and effort to transform clinical trials and enable people with cancer to participate in clinical trials closer to home. Three key strategies are identified to address major barriers: confront challenges with the interpretation of US Food and Drug Administration Form 1572 requirements (Statement of Investigator); broaden acceptance of local laboratories and imaging centers; and invest in the creation of effective, sustainable partnerships between research centers and local providers.

Researcher Experience and Comfort With Telemedicine and Remote Patient Monitoring in Cancer Treatment Trials

BACKGROUND

Since the onset of COVID-19, oncology practices across the US have integrated telemedicine (TM) and remote patient monitoring (RPM) into routine care and clinical trials. The extent of provider experience and comfort with TM/RPM in treatment trials, however, is unknown. We surveyed oncology researchers to assess experience and comfort with TM/RPM.

METHODS

Between April 10 and June 1, 2022, we distributed email surveys to US-based members of the American Society of Clinical Oncology (ASCO) whose member records indicated interest or specialization in clinical research. We collected respondent demographic data, clinical trial experience, workplace characteristics, and comfort and experience with TM/RPM use across trial components in phase I and phase II/III trials. TM/RPM was defined as clinical trial-related healthcare and monitoring for patients geographically separated from trial site.

RESULTS

There were 141 surveys analyzed (5.1% response rate). Ninety percent of respondents had been Principal Investigators, 98% practiced in a norural site. Most respondents had enrolled patients in phase I (82%) and phase II/III trials (99%). Across all phases and trial components, there was a higher frequency of researcher comfort compared to experience. Regarding remote care in treatment trials, 75% reported using TM, RPM, or both. Among these individuals, 62% had never provided remote care to trial patients before the pandemic.

CONCLUSION

COVID-19 spurred the rise of TM/RPM in cancer treatment trials, and some TM/RPM use continues in this context. Among oncology researchers, higher levels of comfort compared with real-world experience with TM/RPM reveal opportunities for expanding TM/RPM policies and guidelines in oncology research.

Designing mHealth Apps to Incorporate Evidence-Based Techniques for Prolonging User Engagement

Maintaining user engagement with mobile health (mHealth) apps can be a challenge. Previously, we developed a conceptual model to optimize patient engagement in mHealth apps by incorporating multiple evidence-based methods, including increasing health literacy, enhancing technical competence, and improving feelings about participation in clinical trials. This viewpoint aims to report on a series of exploratory mini-experiments demonstrating the feasibility of testing our previously published engagement conceptual model. We collected data from 6 participants using an app that showed a series of educational videos and obtained additional data via questionnaires to illustrate and pilot the approach. The videos addressed 3 elements shown to relate to engagement in health care app use: increasing health literacy, enhancing technical competence, and improving positive feelings about participation in clinical trials. We measured changes in participants' knowledge and feelings, collected feedback on the videos and content, made revisions based on this feedback, and conducted participant reassessments. The findings support the feasibility of an iterative approach to creating and refining engagement enhancements in mHealth apps. Systematically identifying the key evidence-based elements intended to be included in an app's design and then systematically testing the implantation of each element separately until a satisfactory level of positive impact is achieved is feasible and should be incorporated into standard app design. While mHealth apps have shown promise, participants are more likely to drop out than to be retained. This viewpoint highlights the potential for mHealth researchers to test and refine mHealth apps using approaches to better engage users.

TBCRC 057: Survey about willingness to participate in cancer clinical trials during the pandemic

BACKGROUND

Breast cancer patients experienced heightened anxiety during the pandemic. Also, modifications to clinical trial activities allowing for virtual platforms, local assessments, and greater flexibility were introduced to facilitate participation. We sought to evaluate the association between pandemic-related anxiety and willingness to participate in trials and how pandemic-era modifications to trial activities affect the decision to participate.

METHODS

We conducted an online survey from August to September, 2021 of patients with breast cancer assessing pandemic-related anxiety; clinical trials knowledge and attitudes; willingness to participate during and before the pandemic; and how each modification affects the decision to participate. Fisher's exact tests evaluated differences in proportions and two-sample t-tests evaluated differences in means. The association of pandemic-related anxiety with a decline in willingness to participate during compared to prior to the pandemic was modeled using logistic regression.

RESULTS

Among 385 respondents who completed the survey, 81% reported moderate-severe pandemic-related anxiety. Mean willingness to participate in a trial was lower during the pandemic than prior [2.97 (SD 1.17) vs. 3.10 (SD 1.09), (p < 0.001)]. Severe anxiety was associated with higher odds of diminished willingness to participate during the pandemic compared to prior (OR 5.07). Each of the modifications, with the exception of opting out of research-only blood tests, were endorsed by >50% of respondents as strategies that would increase their likelihood of deciding to participate.

CONCLUSIONS

While pandemic-related anxiety was associated with diminished willingness to participate in trials, the leading reasons for reluctance to consider trial participation were unrelated to the pandemic but included worries about not getting the best treatment, side effects, and delaying care. Patients view trial modifications favorably, supporting continuation of these modifications, as endorsed by the National Cancer Institute and others.

Narrative review of telemedicine applications in decentralized research

Telemedicine enables critical human communication and interaction between researchers and participants in decentralized research studies. There is a need to better understand the overall scope of telemedicine applications in clinical research as the basis for further research. This narrative, nonsystematic review of the literature sought to review and discuss applications of telemedicine, in the form of synchronous videoconferencing, in clinical research. We searched PubMed to identify relevant literature published between January 1, 2013, and June 30, 2023. Two independent screeners assessed titles and abstracts for inclusion, followed by single-reviewer full-text screening, and we organized the literature into core themes through consensus discussion. We screened 1044 publications for inclusion. Forty-eight publications met our inclusion and exclusion criteria. We identified six core themes to serve as the structure for the narrative review: infrastructure and training, recruitment, informed consent, assessment, monitoring, and engagement. Telemedicine applications span all stages of clinical research from initial planning and recruitment to informed consent and data collection. While the evidence base for using telemedicine in clinical research is not well-developed, existing evidence suggests that telemedicine is a potentially powerful tool in clinical research.

Telehealth and Technology: New Directions in Cancer Care

ABSTRACT

Telehealth is a broad concept that refers to any delivery of health care in real time using technologies to connect people or information that are not in the same physical location. Until fairly recently, telehealth was more aspiration than reality. This situation changed radically due in part to the COVID-19 pandemic, which led to a near-overnight inability for patients to be seen for routine management of chronic health conditions, including those with cancer. The purpose of this brief narrative review is to outline some areas where emerging and future technology may allow for innovations with specific implications for people with a current or past diagnosis of cancer, including underserved and/or historically excluded populations. Specific topics of telehealth are broadly covered in other areas of the special issue.

What went right during the COVID crisis: The capabilities of local actors and lasting innovations in oncology care and research

This article will elaborate how oncology care and research was adapted during the COVID pandemic in the Metropole of Lyon (France), including the lasting innovations that came out of the crisis. The research method involved 22 semi-structured qualitative interviews of healthcare professionals, managers, and researchers in the Lyon, France region coming from both public and private academic hospitals. The interviews took place from February 2021-December 2022 in order to assess the long-term adaptations and innovations in cancer care organization in the post-COVID era. The main results show adaptations and innovations in 1) new processes and resources to facilitate disciplinary and interdisciplinary work; 2) harmonization and streamlining of patient journeys. In the discussion section, we will mobilize the capabilities approach, an interdisciplinary social sciences approach that focuses on the capabilities of persons to be and to do, to elaborate the conditions by which local actors were able to be agile, to adapt and to innovate in spite of the healthcare emergency and in coherence with their professional and personal values.

Impact of the coronavirus disease 2019 pandemic on sarcoma management in France: a 2019 and 2020 comparison

Background

The coronavirus disease 2019 (COVID-19) pandemic was an unprecedented shock to the healthcare systems, and its consequences on managing rare cancers are unknown. We investigated COVID-19's impact on the activity of sarcoma-labeled networks by comparing key indicators in 2019-2020 (before and during the pandemic, respectively).

Methods

We compared the incidence of limb and trunk soft tissue sarcomas, surgery rate, surgery center, surgery quality, and surgery delays nationally and in various regions, focusing on the three most severely affected regions.

Findings

In this study, sarcoma incidence did not decrease, and the tumor and patient characteristics were similar in both years. The number of patients who underwent surgery in the labeled centers increased significantly (63% versus 57%, p = 0.015), the rate of R0 resection increased (55% versus 47%, p = 0.004), and the rate of re-excision decreased (12% versus 21%, p < 0.0001). In the univariate analysis, the time to surgery was similar in both years. Cox regression analysis revealed that the factors associated with a longer time to surgery were age > 70 years (p = 0.003), retroperitoneal location (p > 0.001), tumor size (p < 0.001), deep tumors (p < 0.001), and regions (p < 0.001). However, we have observed an increase in the time before surgery in the regions most stroked by the COVID-19 pandemic.

Interpretation

The model of the labeled center network for managing rare tumors was resilient. Paradoxically, the quality indicators improved during the pandemic due to the direct referral of patients with sarcomas to the labeled centers.

Summary

This study shows that a nationwide network organization has made it possible to maintain care for these rare tumors during the pandemic.

Teleoncology: Novel Approaches for Improving Cancer Care in North America

Due to widespread healthcare workforce shortages, many patients living in remote and rural North America currently have reduced access to various medical specialists. These shortages, coupled with the aging North American population, highlight the need to transform contemporary healthcare delivery systems. The exchange of medical information via telecommunication technology, known as telemedicine, offers promising solutions to address the medical needs of an aging population and the increased demand for specialty medical services. This progressive movement has also improved access to quality health care by mitigating the current shortage of trained subspecialists. Minimizing the effects of these shortages is particularly urgent in the care of cancer patients, many of whom require regular follow-up and close monitoring. Cancer patients living in remote areas of North America have reduced access to specialized care and, thus, have unacceptably high mortality and morbidity rates. Teleoncology, or the use of telemedicine to provide oncology services remotely, has the ability to improve access to high-quality care and assist in alleviating the burden of some of the severe adverse events associated with cancer. In this review, the authors describe how recent advances in teleoncology can reduce healthcare disparities and improve future cancer care in North America.

Crisis of the Clinical Trials Staff Attrition After the COVID-19 Pandemic

A survey of clinical research professionals @SWOG indicate that 80% of clinical trial offices are understaffed. Addressing this is critical so progress for people with cancer continues. Read more about lessons learned in the #COVID19 pandemic and how it informs a path forward.

Clinical trial reform in the post-COVID era

The COVID-19 pandemic precipitated the acute and efficient rollout of telehealth and virtual health care around the world. This review article focuses on the adoption of virtual care in the management of oncology patients, and discusses how virtual care offers the potential for large-scale, positive impacts on access to clinical trials. Virtual care during and following the peak of the pandemic has been found to be both safe and efficacious for oncology patients. Features, such as wearable health technologies, remote monitoring, home visits, and investigations being done closer to home, represent just some of the strengths of the virtual assessment rollout that were successfully utilized. One of the primary criticisms of oncological clinical trials is that clinical trial participants are not always representative of the patient populations treated in routine practice. This is in part due to stringent inclusion criteria and more broadly pertains to a lack of access to clinical trials, many of which are geographic as most trials are conducted in an urban, academic, or 'centralized' center. This paper seeks to discuss the barriers to clinical trial participation and to propose that the virtual care transformation that occurred during the pandemic has equipped oncological clinicians and researchers with the tools to better address these obstacles. A review of the literature on the impact of the virtual care rollout during and after the peak of the COVID-19 pandemic both locally and abroad was conducted. It is proposed that improving patient access through the decentralization of clinical trials has the potential to enhance evidence-based, real-world data, and to produce generalizable trial results that ultimately improve patient outcomes.

Quantifying the impact of the COVID-19 pandemic on cancer center clinical trial operations

BACKGROUND

Oncology clinical trials are complex, and the COVID-19 pandemic caused major disruptions in 2020.

METHODS

Using its networking and sharing of best practices, the Association of American Cancer Institutes, comprising 105 cancer centers, solicited a longitudinal series of voluntary surveys from members to assess how clinical trial office operations were affected. The surveys showed that centers were able to keep oncology trials available to patients while maintaining safety. Data were collected regarding interventional clinical trial accruals for the calendar years 2019, 2020, and 2021.

RESULTS

Data demonstrated a sizeable decrease in interventional treatment trial accruals in both 2020 and 2021 compared with prepandemic figures in 2019. No cancer center reported an increase in interventional treatment trial accruals in 2020 compared with 2019, with most centers reporting a moderate decrease. In mid-2022, 15% of respondents reported an increasing trend, 31% reported no significant change, and 54% continued to report a decrease.

CONCLUSIONS

The pandemic necessitated rapid adoption of trial operations, with the emergence of several best practices, including remote monitoring, remote consenting, electronic research charts, and work-from-home strategies for staff. The national infrastructure to conduct trials was significantly affected by the pandemic, with noteworthy resiliency, evidenced by improvements in efficiencies and patient-centered care delivery but with residual capacity challenges that will be evident for the foreseeable future.

A nationwide pilot study on breast cancer screening in Peru

Introduction

A high prevalence of advanced breast cancer (BC) is a common scenario in Latin America. In Peru, the frequency of BC at Stages III/IV is ≈50% despite implementation of a programme for breast cancer screening (BCS) along the country. We carried out a study to assess the feasibility and develop an instrument to evaluate the knowledge, barriers and perception about BCS in a nationwide pilot study in Peru among candidates for BCS.

Methods

We conducted a systematic review of 2,558 reports indexed in PubMed, Scopus, Web of Science, Medline-Ovid and EMBASE, regarding to our study theme. In total, 111 were selected and a 51-items survey was developed (eight items about sociodemographic characteristics). Patients were recruited in public hospitals or private clinics, in rural and urban areas of nine departments of Peru.

Results

We surveyed 488 women from: Lima (150), Cajamarca (93), Ica (59), Arequipa (56), Loreto (48), Ancash (38), Junín (15), Puerto Maldonado (15) and Huancavelica (14); 27.9% of them were from rural areas. The mean of age was 53.3 years (standard deviation ± 9.1). Regarding education level, 29.8% had primary, 33.2% secondary and 37.0% higher education. In total, 28.7% of women did not know the term 'mammogram' and 47.1% reported never receiving a BCS (36.9% from urban and 73.5% from rural population). In women that underwent BCS, only 67% knew it is for healthy women. In total, 54.1% of patients had low levels of knowledge about risk factors for BC (i.e. 87.5% of women respond that injuries in the breast produce cancer). Cultural, economic and geographic barriers were significantly associated with having a mammogram where 56.9% of participants considered a cost ≤ 7 USD as appropriate. Mammogram was perceived as too painful for 54.9% of women. In addition, women with a self-perception of low-risk for BC and a fatalistic perception of cancer were less likely to have a BCS.

Conclusion

We found that it is feasible to conduct a large-scale study in Peru. The results of this pilot study highlight an urgent need of extensive education and awareness about BCS in Peru.

Germain D, Mohile S, Hudson MF. Enrolling Older Adults Onto National Cancer Institute-Funded Clinical Trials in Community Oncology Clinics: Barriers and Solutions

In April 2021, the National Cancer Institute (NCI) Division of Cancer Prevention collaborated with the NCI Division of Cancer Treatment and Diagnosis to produce a virtual workshop that developed recommendations for enhancing NCI-sponsored clinical trial accrual of older adults. Prior to the workshop, a multidisciplinary group of stakeholders (eg, community oncologists, advanced practice practitioners, clinic and research staff, and patient advocates) gathered information related to accrual of older adults to clinical trials from the literature. Subsequently, a survey was conducted to detail NCI Community Oncology Research Program members' perspective on accrual barriers for this population; 305 individuals responded to the survey. Barriers to clinical trial accruals included comorbidity-attributed trial ineligibility, transportation and time issues, concern that the proposed regimen is too toxic for older adults, patient or family caregiver declined participation, and lack of trials relevant to older patients. Identified solutions included broadening clinical trial inclusion criteria, increasing the number of clinical trials specifically designed for older adults, simplifying consent forms, improving recruitment materials for older adults and their families, and facilitating transportation vouchers. At the workshop, participants, including stakeholders, used prior literature and survey results to develop recommendations, including interventions to address clinician bias, implement geriatric assessment, and promote clinician and staff engagement as mechanisms to improve accrual of older adults to clinical trials.

An Impact of COVID-19 on Cancer Care: An Update

The world has been affected socioeconomically for the last two years due to the emergence of different variants of the COVID-19 virus. Vaccination is the major and most efficient way to prevent the widening of this pandemic. Those who are having comorbidities are more vulnerable to serious infections due to their immunocompromised state. Additionally, cancer patients could be at significant risk for COVID-19. In this pandemic era, the diagnosis and treatment of cancer were significantly affected. Clinical trials at the initial stage were performed on healthy or COVID-19 infected patients. This produces a greater level of hesitancy in cancer patients. This review article provide an update regarding the vaccination and treatment for COVID-19 in patients with cancer and future directions.

Testosterone and long pulse width stimulation (TLPS) for denervated muscles after spinal cord injury: a study protocol of randomised clinical trial

INTRODUCTION

Long pulse width stimulation (LPWS; 120-150 ms) has the potential to stimulate denervated muscles and to restore muscle size in denervated people with spinal cord injury (SCI). We will determine if testosterone treatment (TT)+LPWS would increase skeletal muscle size, leg lean mass and improve overall metabolic health in persons with SCI with denervation. We hypothesise that the 1-year TT+LPWS will upregulate protein synthesis pathways, downregulate protein degradation pathways and increase overall mitochondrial health.

METHODS AND ANALYSIS

Twenty-four male participants (aged 18-70 years with chronic SCI) with denervation of both knee extensor muscles and tolerance to the LPWS paradigm will be randomised into either TT+neuromuscular electrical stimulation via telehealth or TT+LPWS. The training sessions will be twice weekly for 1 year. Measurements will be conducted 1 week prior training (baseline; week 0), 6 months following training (postintervention 1) and 1 week after the end of 1 year of training (postintervention 2). Measurements will include body composition assessment using anthropometry, dual X-ray absorptiometry and MRI to measure size of different muscle groups. Metabolic profile will include measuring of basal metabolic rate, followed by blood drawn to measure fasting biomarkers similar to hemoglobin A1c, lipid panels, C reactive protein, interleukin-6 and free fatty acids and then intravenous glucose tolerance test to test for insulin sensitivity and glucose effectiveness. Finally, muscle biopsy will be captured to measure protein expression and intracellular signalling; and mitochondrial electron transport chain function. The participants will fill out 3 days dietary record to monitor their energy intake on a weekly basis.

ETHICS AND DISSEMINATION

The study was approved by Institutional Review Board of the McGuire Research Institute (ID # 02189). Dissemination plans will include the Veteran Health Administration and its practitioners, the national SCI/D services office, the general healthcare community and the veteran population, as well as the entire SCI community via submitting quarterly letters or peer-review articles.

TRIAL REGISTRATION NUMBER

NCT03345576.

Virtual oncology research-different models and lessons learned

PURPOSE OF REVIEW

The COVID-19 pandemic posed several challenges to cancer research including halting of trials, reduced recruitment and protocol violations related to inflexible processes followed in clinical trials. Researchers adopted innovative measures to mitigate these problems and continue studies without compromising their quality. This review collates these adaptations that could well continue after the pandemic.

RECENT FINDINGS

The COVID-19 pandemic forced researchers globally to adopt innovative measures to overcome the challenges of the pandemic. These included protocol amendments to adjust to the pandemic and travel restrictions, and increased use of digital technologies. 'Virtual' clinical trials were conducted increasingly with adaptations in ethics and regulatory approvals, patient recruitment and consenting, study interventions and delivery of study medications, trial assessments, and monitoring. Many of these adaptations are safe and feasible, without compromising study quality and data integrity. Although these may not be universally applicable in all types of research, they bring many benefits including more diverse patient participation, less burden on patients for study procedures and reduced resources to conduct trials.

SUMMARY

The COVID-19 pandemic has affected cancer research adversely; however, learnings from the pandemic and adaptations from researchers are likely to improve the efficiency of clinical research beyond the pandemic.

The audiogram: Detection of pure-tone stimuli in ototoxicity monitoring and assessments of investigational medicines for the inner ear

Pure-tone thresholds have long served as a gold standard for evaluating hearing sensitivity and documenting hearing changes related to medical treatments, toxic or otherwise hazardous exposures, ear disease, genetic disorders involving the ear, and deficits that develop during aging. Although the use of pure-tone audiometry is basic and standard, interpretation of thresholds obtained at multiple frequencies in both ears over multiple visits can be complex. Significant additional complexity is introduced when audiometric tests are performed within ototoxicity monitoring programs to determine if hearing loss occurs as an adverse reaction to an investigational medication and during the design and conduct of clinical trials for new otoprotective agents for noise and drug-induced hearing loss. Clinical trials using gene therapy or stem cell therapy approaches are emerging as well with audiometric outcome selection further complicated by safety issues associated with biological therapies. This review addresses factors that must be considered, including test-retest variability, significant threshold change definitions, use of ototoxicity grading scales, interpretation of early warning signals, measurement of notching in noise-induced hearing loss, and application of age-based normative data to interpretation of pure-tone thresholds. Specific guidance for clinical trial protocols that will assure rigorous methodological approaches and interpretable audiometric data are provided.

Oncology During the COVID-19 Pandemic: a Lockdown Perspective

Purpose for Review

This perspective piece aims to understand the impacts of the COVID-19 pandemic on the field of oncology, exploring the factors provoking a fall in cancer diagnostic rates, interruption of cancer screening programmes, disruption of oncological treatment and adjuvant care, and the necessary adaption oncological practice has undergone (and will be required to undergo) post-pandemic, including the shift to digital consultations.

Recent Findings

During the COVID-19 pandemic, the field of oncological research has faced significant challenges. Yet, innovation has prevailed with new developments being made across the globe. Looking to the future of oncology, this piece will also suggest potential solutions to overcome the late-stage ramifications of the COVID-19 pandemic.

Summary

The COVID-19 pandemic has triggered a global health crisis, the ramifications of which have reached every corner of the world and overwhelmed already overburdened healthcare systems. However, we are still yet to see the full domino effect of the pandemic as it continues to reveal and exacerbate pre-existing weaknesses in healthcare systems across the world.