A Discussion with Michael L. Steinberg, MD, FASTRO, FACR
Cancer growth and oncology care did not stop during the COVID-19 pandemic, and oncologists, healthcare workers, and patients came together to overcome challenges and produce incredible solutions that may be with us for many years. Within the wider scope of healthcare, rapid legislative and operation reform, and comparisons to previous public reactions to pandemics, such as the acquired immunodeficiency syndrome (AIDS) crisis in the 1980s, have provided interesting takeaways that we can analyze.
We sat down with Michael L. Steinberg, MD, FASTRO, FACR, Professor and Chair, Department of Radiation Oncology, David Geffen School of Medicine, University of California-Los Angeles (UCLA), and past leader of the American Society for Radiation Oncology, and asked him to share his perspective as an experienced figure and influencer in radiation oncology and future-focused cancer care. Looking back on the healthcare industry’s initial response to the COVID-19 pandemic across the United States and the world at large, we asked, “How well did we respond?” and “What does the future hold?”
Facing Immediate Challenges: Analyzing Our Initial Response
Dr Steinberg began by reflecting on the urgency and timeliness of introducing new processes to combat COVID-19’s initial spread. Frontline healthcare workers across the United States were effectively “feeling around in the dark” when it came to ever-evolving safety measures and mandates, and as a result, they needed to adapt quickly and consistently to keep patients as safe as possible. In addition, the lack of personal protective equipment resources for physicians and staff threw many healthcare systems into a panic during the first few months, requiring creative workarounds to move forward during difficult periods.
“At the time, we did not have the necessary processes in place, as we do now,” Dr Steinberg said, referring to the unknowns of the early stage of the pandemic. “There was a significant period of time when we did not know where the virus was coming from or how it spread.” Given how much is known now, and the incredible amount of research that has been done to get to this point, it is almost inconceivable how little was known at the end of 2019 and the beginning of 2020.
Analyzing the virus’s scope and the public’s reaction, Dr Steinberg compared COVID-19’s initial wave and spread to the way in which AIDS impacted the United States in the 1980s. “The more seasoned, grey-haired folks had seen a different version of this type of health crisis in the AIDS epidemic, as there was a long period of time when we did not know the origins of the virus or how it spread,” he said. However, the dissemination of information through the Internet was a major differentiator in how the public was able to gather information and react to the spread of COVID-19 versus AIDS. While the 2 viruses are drastically different, comparisons can be drawn regarding their scope, public reaction, and societal impact.
“Once we knew generally about the respiratory nature of the COVID-19 virus, we worked rapidly to prepare our facility, with our faculty working around 100 hours a week. This resulted in everything being done and ready at UCLA in 2 weeks,” Dr Steinberg said. This rapid pace was incredible, and even more incredibly, it was not unique to UCLA’s School of Medicine—it was being applied in cancer centers, hospitals, and care facilities everywhere.
Rapid change management was one of the highlights of healthcare’s resolve against the pandemic. Healthcare workers’ efforts were combined with technologic advancements that made providing care easier and safer. For example, Dr Steinberg credited UCLA’s early adoption of ultra-hypofractionation radiotherapy as a game changer in providing care faster, when it was needed the most, since the department was one of the first in the United States to popularize hypofractionation. Going all in on future-facing therapy and faculty and instituting processes that better benefited the patient in the past 5 to 10 years saved time, effort, and lives during the pandemic, as the radiation oncology team at UCLA was able to move past barriers to care and ensure safe and effective treatment.
To the point of continued developments in healthcare before and during COVID-19, legislation regarding telemedicine and general operations also played a huge role in the industry’s swift adaptation. Brought about by the suddenness of a global emergency, we can look back on the initial wave in early 2020 with an appreciation of how frontline workers and adaptable healthcare systems got us to where we are today and how they will help us continue to improve in the future.
Potential Long-Term Effects in Oncology: What Is the 20-Year Timetable?
When asked how he views the first 2 years of the pandemic in retrospect, Dr Steinberg responded, “Talk to me in another 6 months.” He considers issues related to delayed cancer diagnoses to be the most interesting takeaway from COVID-19 for oncology, adding that as we move through 2022, the effects will become more visible. In the previous year, more advanced forms of cancer appeared due to the widespread avoidance of medical procedures and checkups. The American College of Radiation Oncology is already observing this in cancer centers across the United States.
What long-term effects will impact healthcare and oncology if we lengthen the timeline to 20 years instead of 2? Considering how little is definitively known about long-term developments of COVID-19 in the body, with some reporting side effects as significant as losing the sense of smell and taste for an indeterminable amount of time, a larger perspective on the virus’s overall impact is needed. For Dr Steinberg, asking “what if” questions such as, “What if this disease has unknown stigmata and sequelae developing years down the road?” puts the overall impact of COVID-19 back in the dark.
In terms of oncology care, Dr Steinberg posited that his main indefinite concern is the development of cancer in COVID-19 survivors. “I have no evidence that a link exists or anything, but there are a whole lot of questions that are yet to be asked,” he said, adding that his core concern lies in the “novel” nature of the virus. There has been nothing exactly like this observed in the past, and as our knowledge grows, so will our questions for the foreseeable future.
“These questions are going to pop up and hit us in the face, and in the next 6 months. Many of them will affect what I do day-to-day for patients,” he said, bringing the focus back to the area of most importance for all healthcare workers.
Addressing Equity and the Disparity of Care
It would be remiss to analyze the United States’ response to COVID-19 without discussing how the pandemic highlighted disparities in care. Disadvantaged groups experienced higher infection and mortality rates due to a variety of factors. The virus spread more rapidly in tighter communities, and among individuals who had blue-collar jobs that lacked work-from-home flexibility or adequate safety procedures and those with restricted access to healthcare. As a result, the virus, which was already incredibly infectious, became much more serious for many populations.
Several of these disadvantaged groups also have lower vaccination rates due to economic reasons and an ingrained distrust in healthcare institutions. For example, Dr Steinberg cited historical public health issues for African Americans, dating all the way back to Tuskegee and generations before, sowing a general mistrust of the healthcare system. “There are always history and cultural effects intertwined in the system,” he said.
Ensuring equity and combating disparities was brought into focus not just in general healthcare, but on a more specific level in cancer care, as we see how the previously mentioned advanced cancer stages and diagnosis delays will disproportionately impact specific ethnic and economic groups. The work that needs to be done at an organizational level includes understanding why this happens and instituting proactive measures in the event that a national or international health emergency occurs again. Creating health policies and practices that specifically target systemic issues, such as poverty and educational gaps, which are disproportionately represented in different ethnic minorities, is the key to ensuring safety for all Americans, on the basis of equity.
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