Impact of COVID-19 on the Equity of Cancer Care Delivery for HNC
Patients
First, COVID-19-associated changes in healthcare delivery may widen
existing disparities in timely diagnosis and treatment of HNC as a
result of reduced access to health care providers. For patients with
HNC, access to and receipt of timely treatment across the cancer care
continuum is critical to optimal oncologic
outcomes.18,19 It is therefore not surprising that
racial and ethnic differences in timely treatment are strongly
associated with racial and ethnic differences in oncologic
outcomes.8,11-15 Care during the COVID-19 pandemic has
brought about an abrupt and precipitous reduction in the number of
patients accessing HNC-related care.20 There has also
been an associated transformation in the method of care delivery for
patients with HNC, with a shift towards telemedicine in lieu of
in-person consultation and follow-up.20,21 However,
access to telehealth is a privilege not shared by
all.22 Studies across a variety of disease states have
demonstrated that telehealth-based interventions are neither culturally
appropriate nor tailored which may result in low uptake among African
American and Hispanic/Latino communities, exacerbating disparities in
access.23 The specific financial, structural, and
institutional characteristics of health care systems that affect racial
and ethnic differences in care also require attention. The hospitals
where African Americans, Hispanic/Latino, and other racial/ethnic
minorities tend to seek care are often less likely to have the resources
and may have less capacity for a comprehensive telehealth program,
further creating a divide.24 Many telehealth platforms
require the use of electronic devices with certain software
requirements, which may not be readily available to low-income and
racial/ethnic minority patients.25 Furthermore, access
to telehealth may also be limited by inadequate health literacy and low
English proficiency, which may be more prevalent in these
populations.26
Second, ongoing initiatives to triage, prioritize, and schedule
HNC-directed therapy to accommodate scarce resources during the COVID-19
pandemic may exacerbate pre-existing racial/ethnic disparities in timely
treatment initiation. The considerations mirror national discourse on
Crisis Standards of Care (CSC) that modify healthcare operations and
preferentially triage lifesaving resources based on likelihood of
survival. The latent threat to minorities in CSC is that when
comorbidities are used in prioritization schemes a proxy for health,
minority patients who, in general, have higher base rates of
comorbidities (and increased risk of mortality) may be deprioritized for
access, placing them in double jeopardy.27 Although
risk stratification protocols have been developed to maximize
objectivity in determining treatment priority,28 the
risk of bias, implicit or explicit, looms large.29
Third, the marked changes in employment status, health insurance
coverage, and dependent care responsibilities may further aggravate
racial/ethnic disparities in access to care and treatment for patients
with HNC, particularly because workers of color are more likely to have
lost employment during the pandemic.30 According to
the US Census, over 36 million Americans have already filed unemployment
claims as of May 14, 2020. Prior to the COVID-19 pandemic, insurance
coverage was strongly linked to stage at diagnosis, timely treatment
initiation, and oncologic outcomes.31,32 The abrupt
loss of insurance coverage for vulnerable patients, compounded by the
financial shock of having to absorb the out-of-pocket costs of care,
will certainly worsen racial disparities in access to multidisciplinary
HNC care. In addition, the increased need for childcare due to school
closings during the COVID-19 pandemic may introduce another barrier to
seeking care that disproportionately burdens racial and ethnic
minorities.