Low Income Countries Hold Lessons for Cancer Care During a Pandemic: Q&A with Dr. Becky DeBoer

In March, as COVID-19 cases were mounting across the country, UCSF oncologist Becky DeBoer and colleagues began preparing for a surge in San Francisco. DeBoer, MD, MA, an assistant professor of Medicine, found herself applying lessons she’d learned training and practicing in low-resource settings like Rwanda, Tanzania, Uganda, Nigeria, and India, countries the World Health Organization considers low-and-middle income-countries (LMICs). Below, DeBoer talks about her experiences and the moral distress physicians face when having to prioritize care for patients when resources are limited.

 

DeBoer came to UCSF in 2016 to pursue a fellowship in medical oncology. She was the first fellow in the Cancer Center’s Global Cancer Fellowship and has pursued an uncharted career path in the emerging academic field of global oncology. She joined the UCSF faculty earlier this year and practices at Zuckerberg San Francisco General Hospital (ZSFGH).

Q. It has been exciting to see the growing body of work around COVID-19 and cancer in terms of the breadth of subject matter and time to publication. When and how did you and the co-authors decide to write a paper for JAMA Oncology, which was published this month?
 

Katherine Van Loon, MD (associate professor of Medicine, and director of the HDFCCC Global Cancer Program), and I actually wrote the initial draft back in March during the first few days of shelter-in-place. We were so struck by the surreal experiences we were having at HDFCCC and ZSFG as we prepared for a possible surge in San Francisco: triaging patients, modifying oncology treatment plans, and cancelling non-emergent procedures. At that time, U.S. institutions were facing alarming projections of resource scarcity and grappling with the prospect of rationing essential cancer care services, which sadly and unjustly is something that our colleagues in low-resource settings face routinely. We found ourselves drawing upon the lessons we’ve learned about priority setting from our work in Rwanda and Tanzania. For example, we have been conducting a project since 2018 to evaluate and improve our system for ethically prioritizing patients for scarce radiotherapy resources in Rwanda. I never imagined that our findings would be so acutely relevant in the U.S., but as the situation unfolded in March, we recognized right away that there was an important opportunity to share our lessons learned with the broader oncology community.
 

Of course, the COVID-19 pandemic has evolved considerably since then. By the time we were responding to reviewer comments in May, the most dramatic projections of resource scarcity and rationing needs had not materialized in most of the U.S., and we actually updated the content of the paper to reflect the more ‘subacute’ and ‘chronic’ phases of resource contraction from the pandemic. Then again when it was time to review proofs in July, COVID-19 resurgences were taking off in new hot spots, and the value of these lessons seemed all the more relevant.
 

 

Q. The term “low resource settings” typically brings particular foreign countries to mind. And while there are plenty of low resource medical settings in the US, are you finding any non-LMIC institutions have been hit hard and needed to set priorities differently? What are you hearing from colleagues and peers in San Francisco and elsewhere? Is anyone doing it well so far?
 

Yes, certainly we have heard from institutions in early COVID-19 epicenters in high-income countries (e.g. Italy, New York, Boston) that had to make very difficult priority setting decisions about cancer care services and workforce allocation with little time to plan. From the beginning there was an impressive collaborative effort among oncology experts across institutions and organizations such as ASCO and NCCN to rapidly develop and compile disease-specific guidelines for prioritizing care. My sense is that the degree to which prioritization efforts reflect the guidance we advise in the paper (e.g. follow fair deliberative procedure, proactively safeguard vulnerable patients, standardize intentional communication with patients and families about resource constraints, etc.) is variable. These efforts take time to implement, which is a luxury that many centers did not have before the initial surge of COVID cases. They are also resource-intensive themselves, and so as with many aspects of the pandemic, they expose disparities in what high-resource and low-resource institutions are able to do.
 

Even in San Francisco, where we have been relatively spared of overwhelmed healthcare systems and workforces, we have seen how cancer care modifications and priority setting have disproportionately affected vulnerable patients. For example, at ZSFG, conversion to telehealth has been particularly challenging since many of our patients do not have the devices, internet, and/or digital literacy for video visits. In addition, the Patient Navigators who typically provide crucial support for our cancer patients have been redeployed for COVID-related work. At both HDFCCC and ZSFG strict guest policies in the infusion center and clinics have posed significant barriers to non-English speaking patients and others who often rely on a family member for communication or health literacy. These barriers, compounded by the social and financial burdens of shelter-in-place and social distancing requirements, have certainly had a significant impact on our most vulnerable patients.

 

Q. For clinicians unaccustomed to this type of situation, is resetting treatment priorities based on limited resources emotionally difficult?
 

Yes. The definition of moral distress is being unable to pursue a morally right action due to external constraints, resulting in negative emotions. Our qualitative research in Rwanda shows that being unable to provide the highest standard of care to all patients because of resource constraints causes frustration, sadness, anger, and guilt among clinicians. From my personal experience practicing in Rwanda, I can corroborate that deciding which patients to prioritize for radiotherapy, or for chemotherapy in the setting of a drug shortage, or for CT scans and MRIs with a limited budget, keeps me awake at night. I can also attest that seeing how practice changes affect our patients at ZSFG disproportionately is emotionally difficult. We know that moral distress can lead to clinician burnout, and even before COVID-19 there was mounting evidence that moral distress and burnout were major problems in oncology.

 

At the same time, many strategies have been developed to mitigate moral distress and burnout, and we now have the opportunity to implement them in earnest at HDFCCC. In Hem/Onc at ZSFG, for example, space for community-building and camaraderie during the pandemic was created through weekly faculty meetings and “office hours” for faculty and fellows over Zoom. We have also established a Hem/Onc Equity Taskforce to proactively address the structural inequalities that we see affecting our patients and staff.

 

Q. What would need to happen to have the recommendations like those in the paper become standardized?
 

Thank you for asking that question! We came to these recommendations through our work with partners in low-income countries, but they draw upon the literature of several diverse disciplines: bioethics, public health, implementation science, serious illness communication, etc. I hope that by synthesizing these key contributions into one set of recommendations through the lens of real-world experience, we have provided a roadmap for programs and institutions.

I think the active ingredients to implement them into practice are institutional initiative, a task force, and enough resources to set up fair deliberative procedure and systems for accountability. At many institutions, existing resources such as clinical practice leaders, ethics committees, clinician wellness programs, and equity initiatives may be leveraged.

 

Q. Before COVID-19 hit the US, what other lessons from your years practicing in settings around the world informed how you practice here?
 

Even before COVID-19, practicing in resource-constrained settings—and also working on national treatment guideline development in Rwanda and Tanzania—had shaped the way I think about the value of what we do in oncology; where we can make the most impact, which interventions are marginally beneficial at best, and how to tailor a clinical approach accordingly. Often when taking care of patients who are struggling with the more immediate threats of poverty, whether in East Africa or in certain parts of San Francisco, an “aggressive” approach to treating and especially curing cancer requires more than just prescribing the right treatment and supportive care; it requires transportation vouchers, food, appointment reminders and no-show tracking, navigation to scans and surgery consultations, mental health counseling, and caregiver support.
 

Working with the NGO Partners in Health, a social justice organization with a mission to provide a preferential option to the poor, taught me that it is our job to provide the comprehensive support and advocacy our patients need to receive the highest standard of care possible. 

 

 

Q. Two pillars of your expertise are medical ethics and practicing oncology in limited-resource settings. When and why did you choose these as being central to your path as a physician?
 

I became interested in both oncology and global health in college, at a time when cancer was essentially absent from the global health agenda—and I wondered, did the “human right to healthcare” that the global health community was so strongly advocating extend to chemotherapy and radiation? After college I worked as a Clinical Research Coordinator in Neuro-Oncology at UCSF, coordinating trials of expensive targeted therapies and personalized therapeutic vaccines in glioblastoma. Trying to reconcile this work with the realization that many children and adults with curable cancers worldwide lacked access to standard treatment, I became interested in ethical questions about resource allocation and equity in global cancer care.

My CRC experience also sparked an interest in research ethics and clinical decision-making, and I decided to pursue a dual MD/MA in Medical Humanities and Bioethics at Northwestern. As a medical student, I conducted a qualitative study about the ethics of cancer treatment decisions and research participation at Tata Memorial Centre in India. Through these interviews, I recognized that the most pressing ethical issue facing most patients in India was not autonomy or paternalism, but rather access to basic cancer care as a matter of social justice, and I wrote my master’s thesis on “The Ethics of Global Cancer Care and Control.”

 

During my medical l training I sought the opportunity to rotate on oncology services in Uganda and Nigeria, and then I worked as an oncology clinician at Butaro Hospital in rural Rwanda after residency with Partners In Health for two years. The ethical challenges that we faced on a day-to-day basis as clinicians at Butaro—and as a program—were particularly salient to me and motivated further training in medical ethics at the MacLean Center at University of Chicago. During medical oncology fellowship at UCSF, I was able to pursue my interest in global oncology and ethics with support from the HDFCCC Global Cancer Program and mentorship from Dr. Katherine Van Loon.

In addition to the project to evaluate and improve radiotherapy prioritization in Rwanda, I am conducting a study of clinical decision-making about non-curative cancer therapy in Rwanda and Tanzania (supported by a Fogarty GloCal Health Fellowship), and a project to adapt evidence-based communication skills training for the Rwandan context (supported by an ASCO Global Oncology Young Investigator Award). I am very fortunate that UCSF, HDFCCC, and ZSFG have been so supportive of this career path!

 

For me, treating cancer in low resource settings (anywhere in the world)—and collaboratively building the capacity and conducting the research necessary to do so—raises countless ethical questions and challenges, yet also addresses a crucial ethical imperative to fight for equity in global cancer care.
 

Read more about the Global Cancer Program.