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.