Rural Cancer Care During a Pandemic

Sidney Health Center in Montana is a not-for-profit community-based medical center that has been an institution in its region for more than 100 years. In 2017, Chad Pedersen, MD—a native of Sidney—joined the health center as its only medical oncologist. Since then, he has cared for a medically underserved population of cancer patients who are often low-income and may live more than a two-hour drive from Dr. Pedersen’s practice. The dawn of COVID-19 has stretched Sidney’s already-scarce medical resources, and Dr. Pedersen and his staff—like many other providers—have had to improvise to maintain the care and treatment of their oncology patients in the midst of a pandemic. He shared with ACCCBuzz his experience of delivering cancer care in rural America during COVID-19.

ACCCBuzz: Tell me about Sidney and your practice.

Dr. Pedersen: Sidney is a small town on the border of Montana and North Dakota, a lone outpost on the Northern Plains. There’s a joke going around town that Sidney was “social distancing” long before we were told to do so. I am the only full-time medical oncologist in a very large area; I serve a geographic area hundreds of miles wide. Our patients are typically very underserved, from primary to specialized care. We have a vulnerable population where COVID-19 could spread quickly.

ACCCBuzz: How widespread is the COVID-19 pandemic in Sidney?

Dr. Pedersen: Sidney got its first confirmed COVID-19 case on April 7. But that doesn’t mean there is not more COVID-19 in our area, because we haven’t been able to test for it. There is a crisis going on across the country, but we are really forgotten about in many ways.

At our practice, we had to make the decision not to test. We don’t test patients who are not that sick, and we don’t test patients who are very sick, because we can’t transfer them. And we don’t have the tests to begin with.

ACCCBuzz: How well prepared are you for a larger outbreak?

Dr. Pedersen: We’ve had some time to prepare, so we’re very fortunate in that way. One big challenge has been determining how to preserve continuity of care if staff get sick. If I am personally out sick or quarantined, who will sustain the clinic? We’ve had to start thinking about that. We are an independent health center, so I don’t have medical oncology partners available to cover me. This is something we should always be prepared for, but COVID-19 has brought it to the forefront.

This has required us to quickly embrace telehealth. I am now seeing a lot of patients remotely, and that could allow me to continue seeing patients at home if I am sick or need to quarantine. Telehealth has been wonderful for my patients. Some must travel two hours to see me, and due to new coverage decisions by CMS [the Centers for Medicare & Medicaid Services], they can now be seen at home.

We’ve been using Zoom to connect to patients by video, which is very different from being on the phone. It allows for nonverbal communication, conveying things you could never get over the phone. Recently after seeing a patient over video in his home, I knew by just looking at him that he was not well.

With Zoom, I can also go over scans with patients. I can screen share and explain to patients what their scans mean. I’ve also been able to connect to family members from around the country and hold family conferences about a patient’s status. That is huge; it’s meant so much to patients. And I am also able to consult with patients who have been admitted to the hospital via telehealth, which eliminates the need for PPE.

ACCCBuzz: How have you had to modify your patient care practices to maintain patient and staff safety?

Dr. Pedersen: We have established protocols for different levels of emergencies that will dictate how we use PPE, control access to the practice, and provide curbside care. Currently, patients check in curbside in their cars, answer screening questions, and are brought in for a temperature check and check-in. Our waiting rooms are kept empty. Several treatments, such as subcutaneous injections, can be given curbside.

To try to keep patients in their communities, we are doing lab testing and scans closer to home when possible. We have come up with a number of strategies for handling patients who present acutely and need hospitalization so we can avoid the emergency room if possible. When possible, we are deferring some patient treatments, such as those for patients in remission.

ACCCBuzz: Have you had access to the safety equipment you need?

Dr. Pedersen: As in many other places, there is a shortage of PPE. We’re not the epicenter of COVID-19, but we are often forgotten about. Initially we had patients wear masks, but we found that there is a real limit on them. Staff has had to carefully consider the use of gloves and gowns, as there is a shortage. Our community has been wonderful in helping out. Residents in our local area have sewn many cloth masks for us.

ACCCBuzz: Has the COVID-19 epidemic negatively affected patient care?

Dr. Pedersen: I have a patient now who has lung cancer and very advanced lung disease. We had planned to start him on chemotherapy and radiation, but we had to defer it initially. Now he is worsening, so we are starting treatment. We have been adapting week by week, reevaluating treatments and surgeries individually so we can defer as necessary. For example, we are deferring surgery on patients with newly diagnosed breast cancer and treating them with other therapies before surgery.

We do not have an intensive care unit, so we send patients who require that level of care to other institutions. Now we are being told by those institutions that we would need to care for such patients here in Sidney. But we have a very limited capacity; there are only so many doctors here.

ACCCBuzz: What do you think the long-term effects of COVID-19 will be on your health center?

Dr. Pedersen: Rural hospitals across the country are already barely getting by. In Sidney, we’ve been lucky to be well-positioned in that we are a regional referral center in a lone outpost on the Northern Plains. But COVID-19 has impacted our ability to continue to provide services.

The cancer center continues to run, but in our main facility, patients are not being seen by their PCPs, they are not getting screened, and we are not seeing a lot of referrals. We are going to lose a lot of money. We were well-positioned going into this, but it has been devastating in terms of decreasing patient volumes, scans not being done, and surgery delays.

Dr. Chad Petersen talked about his experiences as a medical oncologist in a rural practice in an episode of the ACCC podcast, CANCER BUZZ, that aired on December 26, 2019.

For resources on COVID-19 as it applies to the oncology community, visit ACCC’s continually updated Coronavirus Resource page. ACCC members can also access ACCCExchange, a forum that allows them to communicate in real time with their colleagues about how the COVID-19 virus is affecting their communities and their patients.