Evidence Base for Health Care Strategies to Protect Vulnerable Patients During the COVID-19 Pandemic—Reply

Abstract

COMMENT & RESPONSEIn Reply People with cancer experience an increased risk of SARS-CoV-2 vaccine nonresponse and infection, treatment delays from active infection, COVID-19 hospitalization, post-COVID-19 condition (long COVID), and COVID-19 mortality. [1][2][3] Accordingly, in our Editorial, 1 we encouraged cancer centers to provide more comprehensive pandemic support, suggested 10 evidence-based recommendations, and offered volunteer assistance.We appreciate Haslam and Prasad's comments on this evidence base. Foremost, our recommendations 1 focused on patient education about COVID-19, transmission, and mitigation. Haslam and Prasad questioned the importance of educational interventions. Patient education has been the cornerstone of patient-centered oncology for more than 50 years, 4 the foundation of several journals, and an umbrella intervention found to be efficacious in meta-analyses. Education and outreach about high-quality (N95) masking, for example, can be highly successful. 5 Second, Haslam and Prasad asked about N95 efficacy. The National Institute for Occupational Safety and Health establishes and monitors N95 efficacy. The approval process demands years, involves testing N95s to ensure efficacy in blocking greater than 95% of particles that are substantially smaller than virus-laden respiratory aerosol particles, and includes product audits annually and site audits every 2 years to monitor sustained efficacy, inspect materials, and validate quality-control procedures. Third, Haslam and Prasad expressed curiosity about HEPA. HEPA filters undergo rigorous efficacy validation and monitoring tests to ensure they remove more than 99.97% of the small and most-penetrating 0.3micron airborne particles, reducing airborne doses of dust, dirt, pollen, smoke, bacteria, and virus-laden aerosol particles. We were pleased that Haslam and Prasad did not contest the importance of vaccines, testing, treatment, local COVID-19cautious resources, and problem-solving support.We had a difference of opinion on several conceptual points. In our opinion, Haslem and Prasad cited low-rigor studies that were not focused on high-quality masks. Efficacy data come from the methodologies noted above, not later-stage T3 comparative effectiveness trials, which have limitations related to low adherence, low fidelity, and low monitoring. Second, SARS-CoV-2 poses cumulative harm from reinfections. 1,6 An infection or a reinfection remains a notable concern in a population that may have a limited treatment window 2 and limited life span. Third, reasonable mitigation can enhance rather than detract from social well-being by allowing friends and family to visit more safely with less concern toward disrupting a loved one's oncology care. Several types of mitigation require little to no cost.In sum, people with cancer are among the most vulnerable to severe outcomes associated with COVID-19. Health care systems are encouraged to develop comprehensive supports to reduce the risks of COVID-19 among this vulnerable population.

Cancer center matters for appropriate use of immunotherapy at end of life

“…For Michael Hoerger, PhD, author of the accompanying editorial to the study, 2 the study is a reminder that evidence‐based practices are slow to be implemented, particularly at lower volume and in nonacademic centers. Academic and high‐volume centers use immunotherapy more frequently early in the disease when it matters most, whereas low‐volume and nonacademic centers often implement it too late for optimal effectiveness, such as the end of life, he says.…”