As Krista Petruzziello puts it herself, she picked a hell of a time to get cancer.
She got the diagnosis early last month: Breast cancer. An early stage with an excellent prognosis, but still, she’d need surgery and then hormone treatments. The surgery was scheduled for mid-April.
Then the coronavirus hit full force and turned the world upside down — and her treatment plan as well. Her surgery was postponed indefinitely.
“Right now, the risks outweigh the benefits for me,” says Petruzziello, 48. “The risk of infection — and they need the ventilators in the OR.”
Instead, she’ll start hormone treatment first, not a bad option because it could shrink the tumor in advance of surgery, she says, and is often used first in women with larger tumors. But it’s still disconcerting to know this is not the usual order.
“It’s like, 'Here's what we'd be doing in a normal world. But we can't do that for you,’ " she says. "So there are just concerns that come with that, obviously.”
“And I tend to be an anxious person anyway,” she adds. “So, you know, your mind just spins.” And with her job as a licensed insurance agent also taken by the pandemic, “there's nothing else to do but think about it right now.”
Petruzziello is far, far from alone in grappling with concerns about a postponed procedure and wondering what the consequences will be.
In Massachusetts and around the country, hospitals are putting off all but the most urgent treatment to free up space and staff for coronavirus care — and to keep vulnerable patients out of buildings that are documented infection hot spots.
Postponing “elective procedures” may sound like the care is optional, like cosmetic surgery. But the category comprises many much-needed treatments. They include hip and knee replacements for patients living in constant pain, mammograms and colonoscopies to screen for cancer, hernia surgery, kidney donation and much, much more.
At Massachusetts General Hospital, the orthopedics department — which has 45 surgeons whose patients include sports stars — is uneasily quiet now, running at only 3% to 5% of its usual volume, says its chief, Dr. Mitchel Harris. It has even given up its entire sports medicine clinic to be transformed into a respiratory care clinic, where the X-ray machines can serve COVID-19 patients instead of athletes.
It’s treating “only patients with urgent, time-sensitive issues," he says: broken bones and other trauma-related injuries, infections and spinal surgery where delay could lead to permanent damage.
Red Sox pitcher Chris Sale, who recently underwent elbow surgery in Los Angeles despite the pandemic, “would not have been able to have surgery done here,” Harris says.
Challenging Conversations, Uncomfortable Decisions
Across health care, disciplines from orthopedics to cardiology are having to figure out what’s best for non-coronavirus patients during the pandemic.
These are complex adjustments, and they can be tricky to present to patients, says Dr. Harold Burstein, a medical oncologist at Dana-Farber Cancer Institute who has been working on national guidelines for breast cancer treatment during the pandemic.
“We often map out a roadmap for patients, and we say something like, ‘The first step is surgery, and then you'll get radiation, and then you'll get these hormone therapies,’” he says.
These days, with most surgeries canceled, many women will begin treatment with hormone therapies first, like Krista Petruzziello. Extensive evidence shows that for many patients, the outcomes can be just as good whether surgery comes first or second, Burstein says.
“So for our patients, it's a real win-win,” he says, “in the sense that we can preserve these precious health care resources at a time of crisis, but we can also deliver very effective therapy without compromising long term results.”
The trick is getting that across, he says: “I liken this sometimes to going into a three-star Michelin Guide restaurant and saying, 'Instead of the appetizer and then the salad and then the main course and then the dessert, tonight we have a special: We're going to do the main course first and then we're going to have a salad and then an appetizer afterwards, then finish with a dessert. The point is, it all ends up in the same place, .”
Overall, Dr. Burstein says, “I think it is fair to say that we can come up with a good plan so that the vast majority of patients will have outcomes every bit as good as otherwise.”
That’s particularly true for patients with early cancer, whether breast or prostate or other types that lend themselves to re-ordering the treatments. There’s more concern about patients with more advanced cancers who need to continue intensive treatment.
And research on disasters like Hurricane Katrina does suggest that they take a toll on how cancer patients fare, says Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society.
“When we start postponing screenings for cancer early detection, when we start postponing chemotherapy, when we start postponing surgeries, I unfortunately have no doubt that we're going to see impact when we look back at this,” he says. “Obviously, patients who have more advanced disease, if any of their treatments are delayed, the impact is going to be more severe.”
Normally, patients caught in a disaster area can be sent somewhere else for care, but there is no “somewhere else” for American cancer patients right now. And the disruption is likely to continue for months, Lichtenfeld says.
“We're in uncharted territory,” he says of treatment adjustments and delays. “We don't know the impact of these changes. These are not things we want to do. These are delays that we have to do.”
Hospitals will undoubtedly still treat severe, serious cancers, Lichtenfeld says, but may say no to some last-ditch treatments with low odds of success.
“Right now, we're in a situation where we're going to have to make decisions that are not comfortable,” he says.
It Doesn’t Feel 'Elective' To Them
Researchers have looked at the impact of delayed treatment in other contexts — particularly long waiting lists and inability to afford care.
In the VA system, “we found that longer appointment wait times negatively impact health care outcomes for very frail, geriatric populations,” says Julia Prentice, who is now research director for the Betsy Lehman Center for Patient Safety. “But these effects were not seen for less frail populations.”
Not enough is understood about the impact of delays to be able to predict what effect the pandemic-related deferrals will have, she says.
But it is clear that telemedicine care is critical to make up for what would normally be office visits to monitor chronic conditions like diabetes. In the VA system, Prentice says, people with diabetes who had to wait longer to see doctors tended to have worse blood sugar control.
She has several extended family members whose elective procedures — joint replacements and other orthopedic surgeries — have been delayed, “And it doesn’t feel ‘elective’ to them right now,” she says.
But “I will emphasize that the health care system is still doing the right thing by canceling these elective care procedures to protect the capacity,” she says. “It is just a very difficult tradeoff that we're grappling with.”
And there could be an upside: The pandemic is creating an unfortunate but potentially illuminating “natural experiment,” says Dr. Bapu Jena, a professor of health care policy at Harvard Medical School. It could be that in some cases, people who must delay treatment end up better off, because their medical problem resolves on its own and treatment could have caused more harm than good. The widespread delays could bring such benefits to light, he says.
Krista Petruzziello, whose breast cancer surgery is on hold, is doing her best to find upsides, too. She has confidence in her doctors, including Dr. Burstein.
“I'm lucky that I'm not a case where it's like if I don't get this surgery, I'm going to die,” she says. “No one is saying that. And they are telling me it's treatable and curable.”
“And luckily, I have a great support system at home and all my friends,” she adds. One thing, though: “I just miss hugging my friends.”
This segment aired on April 6, 2020.