Lack of Mask Mandates Leaves Cancer Patients Feeling Unprotected

A lack of mask mandates at cancer centers and elsewhere has left cancer patients feeling unsafe and abandoned by society.

Patients reportedly feel unprotected from COVID-19 when the public and health care providers fail to wear masks. Patients have described feeling isolated from the world as an increasingly mask-free society tells them to "just stay home" to avoid SARS-CoV-2 infection. Patients have even reported being harassed by anti-maskers while seeking care and going about their daily lives.

Multiple studies have suggested that wearing face masks can effectively reduce the transmission of SARS-CoV-2, and the World Health Organization (WHO) recommends masking as part of a multipronged approach to protect yourself and others from COVID-19.1-4

Nevertheless, masking requirements have been relaxed or removed across the globe, even in health care settings.5,6 Some health care systems have been lifting and reinstating mask requirements according to the number of COVID-19 cases and/or hospitalizations in the community, while other systems appear to have lifted mask mandates for good and even discourage patients from wearing masks.6-8

Cancer patients and their caregivers have voiced concerns on social media about a lack of masking at cancer centers. This appears to stem from the knowledge that some patients with cancer are at high risk of severe COVID-19 outcomes and are not sufficiently protected by COVID-19 vaccines.9-15

Carrie Honaker posted on Twitter that there was "not a mask in sight" when she went to a cancer center for a checkup in April.

"The cancer center where my mother is treated has dropped their mask requirement. Makes zero sense since they deal with some critically ill patients," Sarah Johnson tweeted in May.

"My cancer center has made masks optional," @lucyhascancer posted a few weeks later. "I can't imagine NOT wearing a mask here. Even though I don't feel like I’m high risk …, I don't want to risk the health of my fellow cancer patients."

Mask Mandates May Vary by State and Community Transmission Level

Houston Methodist, a health care system in Texas, lifted its universal mask mandate in April.6 Staff and patients were no longer required to wear masks in open public spaces, but masks were still required in clinical care areas and for any patient-staff interactions.

A month after this change was made, the universal mask mandate was reinstated due to an increase in COVID-19 cases in the community, according to Firas Zabaneh, managing director of infection prevention and control at Houston Methodist.

"We have a scientific committee that looks at the current COVID-19 situation and decided to move back to masking in public areas due to multiple factors, including case numbers in the community starting to increase, as well as wastewater testing," Zabaneh told Cancer Therapy Advisor.

At present, the Houston Methodist website states that masks are not required in non-clinical areas.16

Another health care system that has modified mask mandates in response to COVID-19 community transmission levels is UnityPoint Health, which has locations in Iowa, Illinois, and Wisconsin.6 In April, some UnityPoint Health locations loosened mask requirements for patients and visitors. Now, according to their websites, most locations have universal mask mandates in place due to an increase in community transmission levels.17

"I’ve been very fortunate in that the community oncology practice where I go in California still requires masking, and their staff has a high incidence of vaccination," Kelly Shanahan, MD, told Cancer Therapy Advisor. Dr Shanahan has been living with metastatic breast cancer since 2013.

"But I have friends in other parts of the country, like Florida, where the oncology center is no longer requiring masking, which I think is insane," Dr Shanahan added.

As in the rest of the United States, masking requirements vary at cancer centers in Florida. Florida Cancer Specialists, which has locations throughout the state, still requires universal masking, according to the organization's website.18 Parrish Medical Center in Titusville has lifted its mask mandate, and Central Florida Cancer Institute, which has locations in Davenport and Lake Wales, actively discourages masking for most patients.7,8

"Health officials say that unless you have cold or flu-like symptoms, you should not wear a face mask," the institute's website says. "It is far more important and effective to wash your hands often and not touch your face."

This statement is not in line with recommendations from the WHO or the US Centers for Disease Control and Prevention (CDC).4,19 However, it is similar to recommendations from the Florida Department of Health, which no longer reference masking as a way to help prevent transmission of SARS-CoV-2.20

When Masking Is Mandated but Not Enforced

Many cancer centers have kept universal mask mandates in place throughout the pandemic.

"At City of Hope, we have had a consistent policy of masking in clinical spaces since March of 2020. This has not changed," Leo Wang, MD, a pediatric hematologist/oncologist at City of Hope in Duarte, California, told Cancer Therapy Advisor.

Dr Wang said that all patients and staff at City of Hope must wear at least a surgical mask in buildings accessible to patients, and all staff must be vaccinated unless they have a medical or religious exemption. For unvaccinated staff, an N95 mask is required.

The American Cancer Society (ACS) does not have an official position on masking. However, the organization mandates masking "in all the places that cancer patients aggregate that are affiliated with the ACS," Arif Kamal, MD, chief patient officer at the ACS, told Cancer Therapy Advisor.

"We hope that our behavior serves as a model example for others," said Dr Kamal, who is also an oncologist at Duke Cancer Center in Durham, North Carolina, where masks are required for patients and employees.

"It really takes both parties to reduce the risk for a person who's at increased risk of severe COVID-19," Dr Kamal said. "We believe very strongly that cancer patients and their caregivers should be wearing masks and that it is an important sign of safety and respect that others around them try to do that as well."

Patients have reported that, despite mask mandates, some cancer center visitors and staff do not wear masks properly, potentially exposing patients to SARS-CoV-2.

On Twitter, Dawn V. Wollen posted about a situation in which a visitor would not wear a mask above his nose, and cancer center employees refused to intervene. @SueSueCurious recounted how an oncologist was doubled-masked during an appointment, but "pulled both masks away from his face multiple times while speaking."

Are Surgical Masks Sufficient?

Some patients have called for universal use of N95, elastomeric, or other high-filtration masks in health care settings, saying surgical masks do not offer adequate protection. Research has suggested that N95s can provide better protection than surgical masks, and elastomeric masks can provide better protection than N95s.21,22

Patients have also reported that, at some cancer centers, they’ve been asked to remove their higher-filtration masks in favor of a surgical mask. Twitter user @CalistaMueller reported having to swap an N95 for a surgical mask while undergoing cancer treatment in April.

User @msun_12 lamented that Memorial Sloan Kettering Cancer Center in New York requires surgical masks, which are "not enough" and "not in line with CDC indoor mask recommendations."

The CDC's website states that health care facilities "may choose to offer well-fitting face masks as a source control option for visitors but should allow the use of a clean mask or respirator with higher-level protection by people who chose that option based on their individual preference."23

Cancer centers asking patients to swap out higher-filtration masks for surgical masks should adopt policies that are "a little more sensible," according to Dr Shanahan.

"So if you are wearing a cloth mask, you need to put on a surgical mask," she said. "But if someone walks in with a surgical mask, or an N95 kind of thing, [the staff should] think a little more and just say, ‘Your mask is fine.’"

When Providers Are Against Masking

Some oncologists and other health care providers have questioned the effectiveness of masking and criticized mask mandates.

"The mask & vaccine mandates are doing far more harm than good," Nicole B. Saphier, MD, wrote on Twitter in February. Dr Saphier is director of breast imaging at Memorial Sloan Kettering Monmouth in Middletown, New Jersey.

Vinay Prasad, MD, a hematologist/oncologist and associate professor at the University of California San Francisco, has also been a vocal opponent of mask mandates, questioning the results of masking studies and calling it "bad public health advice" to recommend wearing N95 masks after COVID-19 vaccination.

In a poll Dr Prasad conducted on Twitter, a majority of respondents who claimed to work in health care settings said they would not wear masks if mandates were dropped.

Staff at Houston Methodist responded positively when the universal mask mandate was lifted there,6 according to Zabaneh.

"We didn't hear any negative feedback at all," Zabaneh said. "Our staff liked the idea. It gave them hope."

When the Public Won't Wear Masks

Since federal and state mask mandates have been lifted in the United States, much of the general public has chosen to forgo masking.24,25

Dr Shanahan is part of multiple patient communities and has had many discussions with community members about how a lack of masking is detrimental to patients with cancer.

"We are angry, and we’re disheartened," Dr Shanahan said, adding that it seems as though the general public doesn't care about cancer patients and other people who are vulnerable to severe outcomes of COVID-19.

"They say, ‘You don't want to get it, you just stay home,’" Dr Shanahan said. "I think there's a lot of anger in our community at the fact that people won't do something so simple as to wear a mask."

"For many people with cancer, we’ve really put our lives on hold," Dr Shanahan explained. "I have a disease that's going to kill me eventually, which is already very isolating. Then with the pandemic, just when it seems like things are improving and I think maybe I can start traveling again and doing things again, mask mandates are dropped and infection rates go up."

Cancer Patients Harassed by Anti-Maskers

Cancer patients have reported being harassed and even assaulted by anti-maskers when trying to access care or when going about their daily lives.

In July 2021, Vice News published an article about a protest outside a cancer center, during which a patient with breast cancer was reportedly "sprayed with bear mace, physically assaulted, and verbally abused" by protestors.26

Dr Shanahan has also had negative encounters with anti-maskers because she wears a mask in public.

"I have had people calling me a ‘sheep’ and rolling their eyes at me," she said. "I will stop them and say, ‘You don't know whether I am immunocompromised. You don't know whether I have COVID and I have my mask on to protect you. You don't know whether I have an elderly person or kid under 5 at home. So how is my mask hurting you?’"

Jon Gluck, who has been living with multiple myeloma for almost 2 decades, has also experienced "a few incidents" related to mask wearing, where he lives in New York City.

"If I’m in a crowded indoor space and very close to somebody, and they don't have their mask on, unfortunately, I need to speak up," Gluck told Cancer Therapy Advisor. He added that he doesn't like to mention his cancer when requesting that people mask around him, but he does bring it up if the person is reluctant to put on their mask.

"Even in the cases where it's gotten contentious, ultimately, people have done it," Gluck said. "They’re just not happy about it."

"Here in New York, we had a period when COVID infection rates and hospitalizations and deaths had dropped to a reasonably low level," Gluck continued. "And again, understandably, people just were very eager to unmask at that point; they were sick of it, and who can blame anyone?"

Gluck wrote an article for The Washington Post in which he shared his experience and asked for others to understand that immunocompromised people are at higher risk of severe COVID-19 outcomes.27 The article was published in January of this year. Less than a month later, New York State lifted its indoor mask mandate.28

"That's when things started getting a little trickier for those of us who are immunocompromised because we would love to take off our masks," Gluck said. "But it just is not as safe for us to do that as it is for other people."

"It's difficult for people who are immunocompromised because there's just a lot less masking overall and a lot less precaution in general," Gluck said. "This is exactly the world I anticipated when I wrote that article."

Disclosures: None of the interviewees declared relevant disclosures.

References

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28. Treisman R. New York lifts indoor mask mandate, with California and N.J. mandates also set to end. NPR. Updated February 9, 2022. Accessed July 5, 2022.

This article originally appeared on Cancer Therapy Advisor