Cancer Topics - Adjusting Cancer Care During Covid-19

ASCO Education Podcast

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Cancer Topics - Adjusting Cancer Care During Covid-19

ASCO Education Podcast

How has Covid-19 has affected cancer care? Listen to the experts discuss postponing and modifying cancer treatment during a pandemic. Moderated by Dr. Helen Chew, featuring Drs. Mary-Beth Percival, Oliver Eng, and Toni Choueiri. We hope you enjoy this episode of the ASCO eLearning Podcast. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us

(Airdate: 4/8/2021)

TRANSCRIPT

[MUSIC PLAYING] SPEAKER 1: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

DR. HELEN CHEW: Hello and welcome to ASCO's podcast episode focused on cancer therapy modifications during the COVID-19 pandemic. My name is Dr. Helen Chew, and I'm a medical oncologist and fellowship program director at the UC Davis Comprehensive Cancer Center. I am pleased to introduce our four guest speakers today.

Dr. Toni Choueiri is a medical oncologist specializing in genitourinary cancers from Dana-Farber Cancer Institute. Dr. Choueiri is also director of the Lank Center for Genitourinary Oncology and the Kidney Cancer Center and a Professor of Medicine at Harvard Medical School. We are also joined by Dr. Mary Elizabeth Percival from Seattle Cancer Care Alliance. Dr. Percival is a hematologist oncologist specializing in AML and myelodysplastic syndrome. She's also serving as an Assistant Professor of Medicine at the University of Washington and Fred Hutchinson Cancer Research Center. Our next guest speaker today is Dr. Oliver Eng, a surgical oncologist and Assistant Professor of Surgery at the University of Chicago. Dr. Eng focuses on treatment of cancers of the abdomen. And finally, we are also joined by Dr. Jennifer Sheng, a medical oncologist and Assistant Professor of Medicine at Johns Hopkins University. Dr. Sheng primarily treats patients with breast cancer.

Many oncologists around the world have been struggling with providing quality care during the pandemic. We are excited to launch a discussion of experiences at different institutions, guidance, and lessons learned that our listeners may apply in their own practice.

Starting with you, Dr. Choueiri, can you tell us about the International Survey of Oncologists you and your colleagues conducted in 2020 about the impact of the pandemic on decision making?

DR. TONI CHOUEIRI: Oh thank you, Dr. Chew. And I want to really thank ASCO for always being at the forefront here of educating the oncology community about the latest here, and we're all in this pandemic. And I remember where everything started, and we were just getting ready to see what we could do to protect our patient, our health care worker, with this novel coronavirus.

So one thing we've done as a group we started an online survey between March and April for a month. And that involved around 340 plus oncologists from 28 countries to understand what is the readiness measure taken by oncologists to protect patient and health care workers here? We really had no idea. We found first that the pandemic, really every country had an outbreak over 99%. PPEs were over 90% provided, and the telemedicine started early on. Around 80% of folks did telemedicine. We also saw that we did not have any routine testing for oncology patients. Only 3% performed systematic testing in all patients.

Then when we asked the oncologists, knowing we had no data, what do they think about systemic therapy? The vast majority thought that systemic therapy here you have to consider comorbidities and age. They also felt that hormonal treatment and tyrosine kinase inhibitors were relatively safe. On the other hand, cytotoxic chemotherapy and immune therapies potentially are not safe. Now we know for the future, when future studies done as part of CCC19 database and other, that there was no increase in mortality with immune checkpoint inhibitor, neither with cytotoxic chemotherapy in large part except perhaps if you consider the timing.

And finally one of the thing the survey showed that oncologists were still focused on neoadjuvant adjuvant first line metastatic disease, but they were kind of hesitant, more hesitant to recommend later line therapy in metastatic disease. So no doubt decision making by oncologists has been influenced by the ongoing COVID pandemic at that time. That was a year ago at the start.

DR. HELEN CHEW: That's really interesting. Did you find any of those results surprising?

DR. TONI CHOUEIRI: Well I would say, I would say no. But a lot of folks have their own biases overall. I do find that in a way that there are, for example, chemotherapy, and second, third line that extended survival and quality of life, folks seem to be hesitant. I didn't find it surprising we didn't have testing that folks-- patient didn't get testing much.

I was a bit surprised that telemedicine immediately made it, and it was around 80%. But that also included phone encounters. But this was overall a very large survey, and the median age of the oncologist were around early 40s.

DR. HELEN CHEW: Finally, can I ask you did you notice any regional differences since these were international survey?

DR. TONI CHOUEIRI: Yeah, absolutely. I mean in Europe there were from Italy and from France, at that time, things were obviously worse. There were some differences. That's a very good question depending where you are. And some of it folks did not experience, but they had the next door, if you want, experience more so than their own experience.

DR. HELEN CHEW: Thank you. Doctors Percival and Sheng, how has the COVID-19 pandemic impacted delivery of cancer therapy at your practice? What have been the major challenges in delivering quality patient care during the pandemic?

DR. MARY-BETH PERCIVAL: This is Mary-Beth Percival Yeah. So I would say that we didn't exactly conduct a survey, but instead my colleagues and I who care for patients hemalignancies at the University of Washington and the Fred Hutchinson Cancer Research Center got together and said, what evidence based guidelines can we come up with that may help to guide the care of patients, particularly those with hemalignancies?

As many of you are aware, the first patient in the US who was diagnosed with COVID-19 was from the Seattle area. So we kind of had a sneak peek into the pandemic before it officially became a pandemic. We've been relatively spared compared to some other areas, but certainly our patients with hemalignancies are at an increased risk of complications.

So I think that there were a number of changes that happened pretty quickly, and Dr. Choueiri spoke about some of these, like the increased use of telehealth when feasible was very rapidly taken on by both patients and providers. And we thought that that was a really important way to really reduce the number of touches that our patients had because they tend to require a lot of visits and a lot of care. And so if we can eliminate any of those we thought that that would be important.

We pretty quickly instituted screening for patients and providers on the entrance to the cancer center and were able to provide masks and rapid COVID testing, which is something that's still going on now and also really increased over time that asymptomatic COVID testing prior to procedures, and surgeries, and scheduled hospitalizations, prior to chemotherapy when possible, doing things like double testing when patients are admitted for a neutropenic fever in the setting of a hemalignancy because its sensitivity with the second test may improve for patients that are on, for example, the transplant service. They get weekly testing even when asymptomatic with the thought that they're at such high risk of complications given their immunosuppression that really knowing about that, and monitoring that, and also for the safety of patients and providers around them that it's important to do that.

I think another shift that really happened in our cancer center was trying to focus on outpatient regimens when that was possible. We weren't really sure what the hospital capacity constraints would be like when the coronavirus pandemic initially hit, and so making sure that that was going to be possible. And for a while we had really stringent transfusion thresholds for our patients who are transfusion dependent. So we lowered some of the hemoglobin and hematocrit goals to really be able to make sure that there was going to be enough supply given the decreased donor availability.

And then I think the final thing that was something that I think really pretty quickly impacted the delivery of cancer care at our site was to have, and I think this is important for oncologists all the time and so sometimes we need a reminder, but having early discussion about goals of care. And I think that it was pretty evident from some of the initial data that came out for patients from China and elsewhere where the pandemic first hit that patients with a history of malignancy or active malignancy, and this has been confirmed by subsequent retrospective studies, had really significantly worse outcomes when they were impacted by the virus. And so I think that that was really important for us to think about in talking to our patients about what they would want, especially when resources might be limited.

DR. JENNIFER SHENG: So similar to Dr. Percival, our group at Johns Hopkins decided to gather the entire group of breast medical oncologists as well as a few select surgical oncologists, radiation oncologists, and patient advocates to help us create guidelines for the management of breast cancer during the COVID-19 pandemic. And our hope from doing this was to create a stage and subtype specific approach to help guide others in their decision making process.

Ultimately, similar to Dr. Percival, I think it's important to remember that cancer care is very individualized, and so of course, we did factor in things such as age as well as comorbidities. And we did try to make visits less frequent when possible. And we ultimately relied pretty heavily on electronic means of communication, phone calls, video visits, and messaging through the electronic medical record. There are other changes that we made during this time. So for instance, we tried to minimize the use of steroids in order to reduce immunosuppression whenever possible, and as a result of doing that we more heavily relied on medications such as olanzapine or other antiemetic regimens. Additionally, we used prophylactic growth factors more frequently to reduce the risk of neutropenic fever.

We also tried to be mindful of patients and having to go to the pharmacy to pick up a lot of the medicines, and we would prescribe 90 day supplies instead of 30 day supplies. And we would try to anticipate this well in advance so that patients could opt for mail order or pharmacy delivery services during this time. For breast cancer specific patients that were on ovarian function suppression we were actually able to work with the insurance companies to allow a monthly self injection at home so they wouldn't have to come to the clinic every four weeks.

And additionally, we really thought about looking at people who are clinically stable and seeing if we could push out some of their imaging. So for instance, echocardiograms which may be done every, let's say three months, sometimes we'd stretch out to four months if they were clinically stable and didn't have any cardiac issues. Other imaging, such as a bone density scan, sometimes we would defer that depending on the situation. And similarly some of those antiresorptive or bone agents that we use in the adjuvant and metastatic setting sometimes we would try to see if we could defer that that timing.

And ultimately I think that we tried to just be really vigilant about how patients were feeling, and we would implement screening calls the day before their visit, inquire about any potential COVID-19 symptoms, and then we would actually screen them for COVID-19 symptoms again on the day of their visit. So overall I think we tried to implement as broadly as possible very safe measures for all of our patients and our staff.

DR. HELEN CHEW: Thank you and follow up to that, either Dr. Percival or Sheng, did you encounter any resistance to some of these changes that you made?

DR. MARY-BETH PERCIVAL: I can comment first. I actually think that there was not a lot of resistance. I think perhaps initially that was because of fear. A lot of patients were really nervous about congregating in any kind of public space even if they realized that we're always weighing the risks and benefits, and that we felt that if we were asking them to come in that the benefit of being seen in person was actually going to be there.

But I think it also speaks to the fact that now later, when sometimes patients don't want to come in when we do think it's actually a lot safer and there hasn't been a lot of transmission in outpatient hospital or clinic settings, I think that now patients are getting very used to telehealth. And in a lot of ways I think that's great, but it's going to be interesting to see what the ramifications are from insurance reimbursement when some of the emergency policies that have been put in place by first the Trump administration, now the Biden administration expire.

So I don't know. It's going to be a hard roll back if we are not able to offer telehealth to the same degree to our patients, especially when I'm for example, at an academic medical center with a really large catchment area. Two weeks ago I was on the phone or telehealth with somebody who is in Fairbanks, Alaska, 1,500 miles away so.

DR. JENNIFER SHENG: Certainly, I agree with that sentiment that we had a wide range of responses. And I think when it was ever with regards to perhaps delaying imaging or delaying treatment there was a lot of anxiety, but if it was, for instance, let's convert to a video visit, I think that probably three quarters of my patients are really enthusiastic about not having to drive to clinics, being able to do this call with me while sitting on their sofa, being able to be next to their significant other or family member was really important because unfortunately in our clinic, even now, we actually don't really allow any visitors with the patient. And I think having that family member or friend, there is so critical. So I think that there was mixed responses overall.

DR. HELEN CHEW: And follow up to that, Doctors Eng and Percival, can you discuss the adjustments to care you have made in response to the COVID-19 pandemic? What major factors played to your decision to modify care?

DR. OLIVER ENG: Sure. So thanks again to ASCO for the invitation to participate in this panel. And so I think from a surgical perspective, it definitely offers some different challenges that are complementary to the challenges that we've discussed already. And so I think when the pandemic arrived and we were just going through the initial stages, there was a lot of uncertainty with the impact of the pandemic itself and surgical patients. And certainly the earlier literature that came out demonstrated high morbidity in patients with cancer who underwent surgery. And so it sort of generated a lot of sort of downstream thoughts about how do we approach surgical cancer care during this pandemic, and how do we navigate this?

And I would say initially, when COVID first arrived, we essentially stopped surgeries, elective surgeries, for some time. And I think that was what was done at many centers as well because we just did not know the consequence of these things. And so a lot of what I wrote about initially when this was happening was that typically surgeries are thought of as being dichotomized between elective and emergent or urgent procedures, but as you know, cancer care falls somewhere in between in most instances. And so I think it's a little bit simplistic to think about it in this dichotomous way.

And so one of the aspects that we talk about was cancer timing and sort of prioritizing surgical cancer cases during this time of not only just postponement but backlog of cases once cases were resumed. And so I think this is kind of a joke, but a lot of us who do surgery were sort of sidelined during this period so then we all just started writing at University of Chicago. And so a lot of us were putting out papers regarding this. And so one of my colleagues, Dr. Kiran Turaga, put out a paper which discussed what was called a safe postponement period of surgery which looked at the fact that the typical time period between when systemic therapy was received, and in what surgery was performed, and is there safe window after that or sort of within that several weeks where we can actually perform surgery and not have a inferior outcome? Again this is just retrospective, it gives us some idea of how to prioritize surgery and that paradigm.

But also it's a complex decision making process, not just the surgery itself, but the institutional resources required for hospitalizations after surgery, the staff that are involved. And not only just staff but trainees as well, and making sure they're compliant with [INAUDIBLE] making sure they're safe, first and foremost, during this whole process. And then working COVID testing into this whole algorithm itself was challenging, to say the least.

DR. HELEN CHEW: Thank you. Dr. Percival, do you want to add anything in addition?

DR. MARY-BETH PERCIVAL: Sure. I think that it's interesting to hear about things from the surgical perspective. It's not something that plays into the care of my patients with hemalignancies, particularly AML, as much as for other specialties, but it's certainly interesting to hear about that. So I think AML is typically a disease that we approach with curative intent, and induction chemotherapy, which is kind of the mainstay of initial treatment, is generally started on an urgent, sometimes emergent, but more of an urgent basis. And so I think we and colleagues were really trying to figure out what would be supported by the literature when we put together recommendations that were published in the Journal of Oncology Practice.

So we have done some trials at our institution, one for what we call early hospital discharge. So instead of keeping patients in the hospital for an entire month, we usually discharge them after receipt of induction chemotherapy to get close outpatient follow up. And so we suggested that that might be something if other centers were equipped to be able to provide the necessary supportive care as an outpatient to consider to decrease hospital utilization, especially in the setting of hospitals being overwhelmed by COVID patients.

We also had a pilot study that was done also out of our center for outpatient induction chemotherapy. So maybe patients could be completely outpatient to receive their chemotherapy, which is not generally how we think about things for AML patients. But there is some supporting literature to suggest that that might be possible. So for example, moving to diffuse large B cell lymphoma, for example, there are some regimens where older patients receive abbreviated chemotherapy and consolidated radiation therapy. So looking at things like that that are reasonable alternatives with evidence behind them was really kind of what we wanted to do to disseminate recommendations and try to be as specific as possible.

I would say one thing that I think is probably going to be talked about on another ASCO podcast but that has come up a lot at our academic medical center is clinical trial enrollment. And so similar to surgeries being cut off completely for a while, clinical trial enrollment was slowed almost to a halt because basically all phase I and phase III trials were closed. Phase II trials were felt, in a lot of cases it was taken on a trial by trial basis, but felt to offer opportunities for patients that they wouldn't be able to achieve in other ways. And I think that there are going to be a lot of long term downstream effects from that clinical trial enrollment stuff that we are yet to see, and I think particularly for patients with relapsed/refractory disease and that kind of thing, that's going to be something that really comes up in the future. And I think also in terms of things like referrals to our center that some of that may decrease as well if we are not able to offer clinical trials to the same extent in the future.

So I think there are just a lot of things that come up when we're caring for patients and modifying therapy for patients. And I think there's going to be a lot that will come out in the future, even though we're moving more towards whatever our new normal is going to be like and having more access to trials and other more standard procedures these days.

DR. HELEN CHEW: Thank you both. Doctors Eng and Sheng, what guidelines or protocols have you relied on to make decisions on therapy adjustments since the start of the pandemic?

DR. OLIVER ENG: Great. Thanks for that question. So in the realm of surgery, we actually, my colleagues at the University of Chicago actually, put out a paper which we, again, like I mentioned, the dichotomization of elective versus non-elective procedures was a bit simplistic. And so we actually devised a scoring system here at University of Chicago. We termed it medically necessary time-sensitive procedures. And so it took into account the procedure itself, the disease, and patient factors. And we were all required to submit a score for each patient we were proposing to do surgery on during this period. And basically, procedures were selected in conjunction with the actual score the patient was assigned, because it was felt to be attributable to appropriate risk within the context of the pandemic.

And so at least at an institutional level, we utilize this not only during the first wave but the second wave as well, and it seemed to be able to triage patients appropriately based on all these aspects. But of course, like we have discussed, cancer care is individualized. And so it is still difficult to try and put a number to a patient, for sure. But we did certainly consider each patient individually with all aspects of their care.

I think from a regional perspective, in the state of Illinois we've come together and formed the Illinois Cancer Collaborative which has developed COVID-19 guidelines as well throughout the state which has been a nice collaboration amongst a lot of the hospitals and distributed amongst the communities. And certainly societal, national recommendations have been put forth as well. The Society of Surgical Oncology has put forth guidelines for multiple disease sites, and so that's been the consensus recommendation from leaders of our society.

I think just to give a little perspective, my specialty is primarily in peritoneal malignancies and metastatic malignancies, and so certainly patients who are undergoing cytoreductive surgery for a low grade disease, for example, was postponed for some time. And patients with higher grade disease were kept on systemic therapy for longer, and then certainly when they're within that window for operations, sort of recommendations for delaying operation dependent on the aggressiveness disease were adjusted accordingly. And so that's just one aspect of all the recommendations that were put forth.

DR. HELEN CHEW: Dr. Sheng?

DR. JENNIFER SHENG: Yeah. So I think we heavily relied on seeing what our peers nationally and internationally did during these times. The COVID-19 Pandemic Breast Cancer Consortium did release guidelines and recommendations. So we certainly relied on those because they provided a tiered approach to prioritizing surgery, radiation, and systemic therapy interventions by urgency, and within those guidelines there was certainly discussion about weighing the risks and benefits of delivering immunosuppressive therapy, about a delay of non urgent surgeries, the use of neoadjuvant systemic therapy due to deferral of many breast surgeries during the initial pandemic, and also discussion of the genomic tumor profiling on core biopsy specimens to guide neoadjuvant therapy decisions.

And so from there, our group thought that it would be prudent to just really gather together and really create more focused guidelines with a few more specifics about how to care for early stage breast cancer, metastatic breast cancer, and I think I briefly highlighted, some of the changes that really applied to many of our patients regardless of their stage. And then I think more specifically for patients who had metastatic breast cancer, for instance, we would try to consider oral regimen as opposed to IV regimens, and really tailoring that to patients and also trying to decrease the total number of visits to the cancer center. We would also defer some of the re-staging scans and lengthen the intervals between scans of patients who are clinically stable. We were able to extend the interval between port flushes for patients to 12 or of longer.

And we really tried to be really cautious when we looked up the side effect profile of a lot of the agents that we use. So for instance, really trying to balance the risk of pneumonitis for the use of immunotherapy, the risk of interstitial lung disease with certain types of [INAUDIBLE] II therapy that have been approved, and really thinking about some of the oral agents that we provide for metastatic hormone receptor positive breast cancer that require some more frequent blood work and labs and seeing what if we could delay that if we were able to implement initial endocrine therapy. So overall I think that everyone was trying to think of ways to keep our patients as safe as possible. And there were quite a few institutions and organizations that gathered, like minded individuals to be able to come up with these guidances.

DR. HELEN CHEW: Thank you both. Dr. Choueiri, in the upcoming months as the vaccination rolls out, do you think you will start reverting to pre-pandemic patient management at your institution?

DR. TONI CHOUEIRI: Oh, thank you for your question. Actually, I mean the short answer is I don't know. I think it's hard to say who is in control. I know who is in control. The virus is in control. Yes, there are a lot of signs, positive signs, happening, but we don't know what later on things going to happen. I personally think that stuff won't go back to normal immediately.

First, we can't expect everyone, all our patients, to be vaccinated despite our recommendation. Second, I would think that some folks are comfortable doing what they learned and they still want to have a mixed telemedicine. I'm talking not just physician but patient. They want a mix of telemedicine, face to face, and we have to see what's the implication of that is. There are some implications, of course, for out-of-state consult if patients have licenses there. There are indication on billing perhaps, although some preliminary data shows that this is going well.

What I want to say is some silver lining, hopefully, that our clinical operation and our clinical trials operation could be a bit more efficient after we learned how to be overall more efficient. We recently wrote with Doctor [INAUDIBLE], a German oncology, a piece about that. I think there will be a transition. The good thing is that there are processes, safety processes, best practices now that we know very well that we didn't know at the beginning of the pandemic, and that actually is reflected by a study we did in the Mass General Brigham Health Care System where we looked at the screening for cancer and compared the three months between March and June index case, the three months where we had the first pandemic, if you will, in the first peak, compared to three months prior, three months after, and three months into 2019. We saw, because of cancellation of a lot of elective procedure, we saw 80% decrease in screening.

But that picked up. It didn't pick up completely, but it did pick up because we have safety measures in place. So I think it will be a gradual increase, and we just have to learn as we go.

DR. HELEN CHEW: Thank you. Yes, it's certainly been a learning process. And I think some of the changes we've made are probably here to stay.

DR. OLIVER ENG: Yeah, I think the one thing that should not be forgotten is the impact on patients and their perception of delays, and it's very easy to think of this from an academic perspective of OK, it's safe to delay because of disease biology, and so and so and, make decisions based on the duration of therapy and so forth. But to call a patient, which all of us have had to do, to delay the therapy for a variety of reasons and explain why. I think it's something that we need to be cognizant of when we are making these decisions and really being transparent with the patients about the fact that we're taking consideration not only their risk but the risk to the community as well. And it's just made things a lot more complex. And time will tell as to the sort of sequelae of everything, all the decisions that are made in this period.

DR. TONI CHOUEIRI: I like that Oliver. I think that's very sensible honestly. I think there's wording. Sometimes it's not from us, it's the patient who want to delay. But I think the word delay does have some negative connotations, and actually, funny enough, when we did our paper in Journal of Oncology about screening, which went down, then up, and compared this, a reporter asked me directly, he said look, these patients were delayed. Did you missed the diagnosis?

And you can't-- it's just a bit, so the word we used is kind of postponed. I think despite it is a bit the same, but I think it looks-- because delay is negative. Delay implicates that we're missing something while it's mostly postponing some things that normally maybe you would this is not BEP for testicular cancer that you would anyhow want to delay, but this is postponed. So this was very sensible, and I agree with you.

DR. HELEN CHEW: Thank you. So that is all we have time for today. Thank you all for your time to share your valuable perspectives. For listeners that want more, look out for upcoming episodes in ASCO's eLearning series on COVID-19's continually evolving impact on cancer care.

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The podcast ASCO Education Podcast has been added to your home screen.

How has Covid-19 has affected cancer care? Listen to the experts discuss postponing and modifying cancer treatment during a pandemic. Moderated by Dr. Helen Chew, featuring Drs. Mary-Beth Percival, Oliver Eng, and Toni Choueiri. We hope you enjoy this episode of the ASCO eLearning Podcast. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us

(Airdate: 4/8/2021)

TRANSCRIPT

[MUSIC PLAYING] SPEAKER 1: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

DR. HELEN CHEW: Hello and welcome to ASCO's podcast episode focused on cancer therapy modifications during the COVID-19 pandemic. My name is Dr. Helen Chew, and I'm a medical oncologist and fellowship program director at the UC Davis Comprehensive Cancer Center. I am pleased to introduce our four guest speakers today.

Dr. Toni Choueiri is a medical oncologist specializing in genitourinary cancers from Dana-Farber Cancer Institute. Dr. Choueiri is also director of the Lank Center for Genitourinary Oncology and the Kidney Cancer Center and a Professor of Medicine at Harvard Medical School. We are also joined by Dr. Mary Elizabeth Percival from Seattle Cancer Care Alliance. Dr. Percival is a hematologist oncologist specializing in AML and myelodysplastic syndrome. She's also serving as an Assistant Professor of Medicine at the University of Washington and Fred Hutchinson Cancer Research Center. Our next guest speaker today is Dr. Oliver Eng, a surgical oncologist and Assistant Professor of Surgery at the University of Chicago. Dr. Eng focuses on treatment of cancers of the abdomen. And finally, we are also joined by Dr. Jennifer Sheng, a medical oncologist and Assistant Professor of Medicine at Johns Hopkins University. Dr. Sheng primarily treats patients with breast cancer.

Many oncologists around the world have been struggling with providing quality care during the pandemic. We are excited to launch a discussion of experiences at different institutions, guidance, and lessons learned that our listeners may apply in their own practice.

Starting with you, Dr. Choueiri, can you tell us about the International Survey of Oncologists you and your colleagues conducted in 2020 about the impact of the pandemic on decision making?

DR. TONI CHOUEIRI: Oh thank you, Dr. Chew. And I want to really thank ASCO for always being at the forefront here of educating the oncology community about the latest here, and we're all in this pandemic. And I remember where everything started, and we were just getting ready to see what we could do to protect our patient, our health care worker, with this novel coronavirus.

So one thing we've done as a group we started an online survey between March and April for a month. And that involved around 340 plus oncologists from 28 countries to understand what is the readiness measure taken by oncologists to protect patient and health care workers here? We really had no idea. We found first that the pandemic, really every country had an outbreak over 99%. PPEs were over 90% provided, and the telemedicine started early on. Around 80% of folks did telemedicine. We also saw that we did not have any routine testing for oncology patients. Only 3% performed systematic testing in all patients.

Then when we asked the oncologists, knowing we had no data, what do they think about systemic therapy? The vast majority thought that systemic therapy here you have to consider comorbidities and age. They also felt that hormonal treatment and tyrosine kinase inhibitors were relatively safe. On the other hand, cytotoxic chemotherapy and immune therapies potentially are not safe. Now we know for the future, when future studies done as part of CCC19 database and other, that there was no increase in mortality with immune checkpoint inhibitor, neither with cytotoxic chemotherapy in large part except perhaps if you consider the timing.

And finally one of the thing the survey showed that oncologists were still focused on neoadjuvant adjuvant first line metastatic disease, but they were kind of hesitant, more hesitant to recommend later line therapy in metastatic disease. So no doubt decision making by oncologists has been influenced by the ongoing COVID pandemic at that time. That was a year ago at the start.

DR. HELEN CHEW: That's really interesting. Did you find any of those results surprising?

DR. TONI CHOUEIRI: Well I would say, I would say no. But a lot of folks have their own biases overall. I do find that in a way that there are, for example, chemotherapy, and second, third line that extended survival and quality of life, folks seem to be hesitant. I didn't find it surprising we didn't have testing that folks-- patient didn't get testing much.

I was a bit surprised that telemedicine immediately made it, and it was around 80%. But that also included phone encounters. But this was overall a very large survey, and the median age of the oncologist were around early 40s.

DR. HELEN CHEW: Finally, can I ask you did you notice any regional differences since these were international survey?

DR. TONI CHOUEIRI: Yeah, absolutely. I mean in Europe there were from Italy and from France, at that time, things were obviously worse. There were some differences. That's a very good question depending where you are. And some of it folks did not experience, but they had the next door, if you want, experience more so than their own experience.

DR. HELEN CHEW: Thank you. Doctors Percival and Sheng, how has the COVID-19 pandemic impacted delivery of cancer therapy at your practice? What have been the major challenges in delivering quality patient care during the pandemic?

DR. MARY-BETH PERCIVAL: This is Mary-Beth Percival Yeah. So I would say that we didn't exactly conduct a survey, but instead my colleagues and I who care for patients hemalignancies at the University of Washington and the Fred Hutchinson Cancer Research Center got together and said, what evidence based guidelines can we come up with that may help to guide the care of patients, particularly those with hemalignancies?

As many of you are aware, the first patient in the US who was diagnosed with COVID-19 was from the Seattle area. So we kind of had a sneak peek into the pandemic before it officially became a pandemic. We've been relatively spared compared to some other areas, but certainly our patients with hemalignancies are at an increased risk of complications.

So I think that there were a number of changes that happened pretty quickly, and Dr. Choueiri spoke about some of these, like the increased use of telehealth when feasible was very rapidly taken on by both patients and providers. And we thought that that was a really important way to really reduce the number of touches that our patients had because they tend to require a lot of visits and a lot of care. And so if we can eliminate any of those we thought that that would be important.

We pretty quickly instituted screening for patients and providers on the entrance to the cancer center and were able to provide masks and rapid COVID testing, which is something that's still going on now and also really increased over time that asymptomatic COVID testing prior to procedures, and surgeries, and scheduled hospitalizations, prior to chemotherapy when possible, doing things like double testing when patients are admitted for a neutropenic fever in the setting of a hemalignancy because its sensitivity with the second test may improve for patients that are on, for example, the transplant service. They get weekly testing even when asymptomatic with the thought that they're at such high risk of complications given their immunosuppression that really knowing about that, and monitoring that, and also for the safety of patients and providers around them that it's important to do that.

I think another shift that really happened in our cancer center was trying to focus on outpatient regimens when that was possible. We weren't really sure what the hospital capacity constraints would be like when the coronavirus pandemic initially hit, and so making sure that that was going to be possible. And for a while we had really stringent transfusion thresholds for our patients who are transfusion dependent. So we lowered some of the hemoglobin and hematocrit goals to really be able to make sure that there was going to be enough supply given the decreased donor availability.

And then I think the final thing that was something that I think really pretty quickly impacted the delivery of cancer care at our site was to have, and I think this is important for oncologists all the time and so sometimes we need a reminder, but having early discussion about goals of care. And I think that it was pretty evident from some of the initial data that came out for patients from China and elsewhere where the pandemic first hit that patients with a history of malignancy or active malignancy, and this has been confirmed by subsequent retrospective studies, had really significantly worse outcomes when they were impacted by the virus. And so I think that that was really important for us to think about in talking to our patients about what they would want, especially when resources might be limited.

DR. JENNIFER SHENG: So similar to Dr. Percival, our group at Johns Hopkins decided to gather the entire group of breast medical oncologists as well as a few select surgical oncologists, radiation oncologists, and patient advocates to help us create guidelines for the management of breast cancer during the COVID-19 pandemic. And our hope from doing this was to create a stage and subtype specific approach to help guide others in their decision making process.

Ultimately, similar to Dr. Percival, I think it's important to remember that cancer care is very individualized, and so of course, we did factor in things such as age as well as comorbidities. And we did try to make visits less frequent when possible. And we ultimately relied pretty heavily on electronic means of communication, phone calls, video visits, and messaging through the electronic medical record. There are other changes that we made during this time. So for instance, we tried to minimize the use of steroids in order to reduce immunosuppression whenever possible, and as a result of doing that we more heavily relied on medications such as olanzapine or other antiemetic regimens. Additionally, we used prophylactic growth factors more frequently to reduce the risk of neutropenic fever.

We also tried to be mindful of patients and having to go to the pharmacy to pick up a lot of the medicines, and we would prescribe 90 day supplies instead of 30 day supplies. And we would try to anticipate this well in advance so that patients could opt for mail order or pharmacy delivery services during this time. For breast cancer specific patients that were on ovarian function suppression we were actually able to work with the insurance companies to allow a monthly self injection at home so they wouldn't have to come to the clinic every four weeks.

And additionally, we really thought about looking at people who are clinically stable and seeing if we could push out some of their imaging. So for instance, echocardiograms which may be done every, let's say three months, sometimes we'd stretch out to four months if they were clinically stable and didn't have any cardiac issues. Other imaging, such as a bone density scan, sometimes we would defer that depending on the situation. And similarly some of those antiresorptive or bone agents that we use in the adjuvant and metastatic setting sometimes we would try to see if we could defer that that timing.

And ultimately I think that we tried to just be really vigilant about how patients were feeling, and we would implement screening calls the day before their visit, inquire about any potential COVID-19 symptoms, and then we would actually screen them for COVID-19 symptoms again on the day of their visit. So overall I think we tried to implement as broadly as possible very safe measures for all of our patients and our staff.

DR. HELEN CHEW: Thank you and follow up to that, either Dr. Percival or Sheng, did you encounter any resistance to some of these changes that you made?

DR. MARY-BETH PERCIVAL: I can comment first. I actually think that there was not a lot of resistance. I think perhaps initially that was because of fear. A lot of patients were really nervous about congregating in any kind of public space even if they realized that we're always weighing the risks and benefits, and that we felt that if we were asking them to come in that the benefit of being seen in person was actually going to be there.

But I think it also speaks to the fact that now later, when sometimes patients don't want to come in when we do think it's actually a lot safer and there hasn't been a lot of transmission in outpatient hospital or clinic settings, I think that now patients are getting very used to telehealth. And in a lot of ways I think that's great, but it's going to be interesting to see what the ramifications are from insurance reimbursement when some of the emergency policies that have been put in place by first the Trump administration, now the Biden administration expire.

So I don't know. It's going to be a hard roll back if we are not able to offer telehealth to the same degree to our patients, especially when I'm for example, at an academic medical center with a really large catchment area. Two weeks ago I was on the phone or telehealth with somebody who is in Fairbanks, Alaska, 1,500 miles away so.

DR. JENNIFER SHENG: Certainly, I agree with that sentiment that we had a wide range of responses. And I think when it was ever with regards to perhaps delaying imaging or delaying treatment there was a lot of anxiety, but if it was, for instance, let's convert to a video visit, I think that probably three quarters of my patients are really enthusiastic about not having to drive to clinics, being able to do this call with me while sitting on their sofa, being able to be next to their significant other or family member was really important because unfortunately in our clinic, even now, we actually don't really allow any visitors with the patient. And I think having that family member or friend, there is so critical. So I think that there was mixed responses overall.

DR. HELEN CHEW: And follow up to that, Doctors Eng and Percival, can you discuss the adjustments to care you have made in response to the COVID-19 pandemic? What major factors played to your decision to modify care?

DR. OLIVER ENG: Sure. So thanks again to ASCO for the invitation to participate in this panel. And so I think from a surgical perspective, it definitely offers some different challenges that are complementary to the challenges that we've discussed already. And so I think when the pandemic arrived and we were just going through the initial stages, there was a lot of uncertainty with the impact of the pandemic itself and surgical patients. And certainly the earlier literature that came out demonstrated high morbidity in patients with cancer who underwent surgery. And so it sort of generated a lot of sort of downstream thoughts about how do we approach surgical cancer care during this pandemic, and how do we navigate this?

And I would say initially, when COVID first arrived, we essentially stopped surgeries, elective surgeries, for some time. And I think that was what was done at many centers as well because we just did not know the consequence of these things. And so a lot of what I wrote about initially when this was happening was that typically surgeries are thought of as being dichotomized between elective and emergent or urgent procedures, but as you know, cancer care falls somewhere in between in most instances. And so I think it's a little bit simplistic to think about it in this dichotomous way.

And so one of the aspects that we talk about was cancer timing and sort of prioritizing surgical cancer cases during this time of not only just postponement but backlog of cases once cases were resumed. And so I think this is kind of a joke, but a lot of us who do surgery were sort of sidelined during this period so then we all just started writing at University of Chicago. And so a lot of us were putting out papers regarding this. And so one of my colleagues, Dr. Kiran Turaga, put out a paper which discussed what was called a safe postponement period of surgery which looked at the fact that the typical time period between when systemic therapy was received, and in what surgery was performed, and is there safe window after that or sort of within that several weeks where we can actually perform surgery and not have a inferior outcome? Again this is just retrospective, it gives us some idea of how to prioritize surgery and that paradigm.

But also it's a complex decision making process, not just the surgery itself, but the institutional resources required for hospitalizations after surgery, the staff that are involved. And not only just staff but trainees as well, and making sure they're compliant with [INAUDIBLE] making sure they're safe, first and foremost, during this whole process. And then working COVID testing into this whole algorithm itself was challenging, to say the least.

DR. HELEN CHEW: Thank you. Dr. Percival, do you want to add anything in addition?

DR. MARY-BETH PERCIVAL: Sure. I think that it's interesting to hear about things from the surgical perspective. It's not something that plays into the care of my patients with hemalignancies, particularly AML, as much as for other specialties, but it's certainly interesting to hear about that. So I think AML is typically a disease that we approach with curative intent, and induction chemotherapy, which is kind of the mainstay of initial treatment, is generally started on an urgent, sometimes emergent, but more of an urgent basis. And so I think we and colleagues were really trying to figure out what would be supported by the literature when we put together recommendations that were published in the Journal of Oncology Practice.

So we have done some trials at our institution, one for what we call early hospital discharge. So instead of keeping patients in the hospital for an entire month, we usually discharge them after receipt of induction chemotherapy to get close outpatient follow up. And so we suggested that that might be something if other centers were equipped to be able to provide the necessary supportive care as an outpatient to consider to decrease hospital utilization, especially in the setting of hospitals being overwhelmed by COVID patients.

We also had a pilot study that was done also out of our center for outpatient induction chemotherapy. So maybe patients could be completely outpatient to receive their chemotherapy, which is not generally how we think about things for AML patients. But there is some supporting literature to suggest that that might be possible. So for example, moving to diffuse large B cell lymphoma, for example, there are some regimens where older patients receive abbreviated chemotherapy and consolidated radiation therapy. So looking at things like that that are reasonable alternatives with evidence behind them was really kind of what we wanted to do to disseminate recommendations and try to be as specific as possible.

I would say one thing that I think is probably going to be talked about on another ASCO podcast but that has come up a lot at our academic medical center is clinical trial enrollment. And so similar to surgeries being cut off completely for a while, clinical trial enrollment was slowed almost to a halt because basically all phase I and phase III trials were closed. Phase II trials were felt, in a lot of cases it was taken on a trial by trial basis, but felt to offer opportunities for patients that they wouldn't be able to achieve in other ways. And I think that there are going to be a lot of long term downstream effects from that clinical trial enrollment stuff that we are yet to see, and I think particularly for patients with relapsed/refractory disease and that kind of thing, that's going to be something that really comes up in the future. And I think also in terms of things like referrals to our center that some of that may decrease as well if we are not able to offer clinical trials to the same extent in the future.

So I think there are just a lot of things that come up when we're caring for patients and modifying therapy for patients. And I think there's going to be a lot that will come out in the future, even though we're moving more towards whatever our new normal is going to be like and having more access to trials and other more standard procedures these days.

DR. HELEN CHEW: Thank you both. Doctors Eng and Sheng, what guidelines or protocols have you relied on to make decisions on therapy adjustments since the start of the pandemic?

DR. OLIVER ENG: Great. Thanks for that question. So in the realm of surgery, we actually, my colleagues at the University of Chicago actually, put out a paper which we, again, like I mentioned, the dichotomization of elective versus non-elective procedures was a bit simplistic. And so we actually devised a scoring system here at University of Chicago. We termed it medically necessary time-sensitive procedures. And so it took into account the procedure itself, the disease, and patient factors. And we were all required to submit a score for each patient we were proposing to do surgery on during this period. And basically, procedures were selected in conjunction with the actual score the patient was assigned, because it was felt to be attributable to appropriate risk within the context of the pandemic.

And so at least at an institutional level, we utilize this not only during the first wave but the second wave as well, and it seemed to be able to triage patients appropriately based on all these aspects. But of course, like we have discussed, cancer care is individualized. And so it is still difficult to try and put a number to a patient, for sure. But we did certainly consider each patient individually with all aspects of their care.

I think from a regional perspective, in the state of Illinois we've come together and formed the Illinois Cancer Collaborative which has developed COVID-19 guidelines as well throughout the state which has been a nice collaboration amongst a lot of the hospitals and distributed amongst the communities. And certainly societal, national recommendations have been put forth as well. The Society of Surgical Oncology has put forth guidelines for multiple disease sites, and so that's been the consensus recommendation from leaders of our society.

I think just to give a little perspective, my specialty is primarily in peritoneal malignancies and metastatic malignancies, and so certainly patients who are undergoing cytoreductive surgery for a low grade disease, for example, was postponed for some time. And patients with higher grade disease were kept on systemic therapy for longer, and then certainly when they're within that window for operations, sort of recommendations for delaying operation dependent on the aggressiveness disease were adjusted accordingly. And so that's just one aspect of all the recommendations that were put forth.

DR. HELEN CHEW: Dr. Sheng?

DR. JENNIFER SHENG: Yeah. So I think we heavily relied on seeing what our peers nationally and internationally did during these times. The COVID-19 Pandemic Breast Cancer Consortium did release guidelines and recommendations. So we certainly relied on those because they provided a tiered approach to prioritizing surgery, radiation, and systemic therapy interventions by urgency, and within those guidelines there was certainly discussion about weighing the risks and benefits of delivering immunosuppressive therapy, about a delay of non urgent surgeries, the use of neoadjuvant systemic therapy due to deferral of many breast surgeries during the initial pandemic, and also discussion of the genomic tumor profiling on core biopsy specimens to guide neoadjuvant therapy decisions.

And so from there, our group thought that it would be prudent to just really gather together and really create more focused guidelines with a few more specifics about how to care for early stage breast cancer, metastatic breast cancer, and I think I briefly highlighted, some of the changes that really applied to many of our patients regardless of their stage. And then I think more specifically for patients who had metastatic breast cancer, for instance, we would try to consider oral regimen as opposed to IV regimens, and really tailoring that to patients and also trying to decrease the total number of visits to the cancer center. We would also defer some of the re-staging scans and lengthen the intervals between scans of patients who are clinically stable. We were able to extend the interval between port flushes for patients to 12 or of longer.

And we really tried to be really cautious when we looked up the side effect profile of a lot of the agents that we use. So for instance, really trying to balance the risk of pneumonitis for the use of immunotherapy, the risk of interstitial lung disease with certain types of [INAUDIBLE] II therapy that have been approved, and really thinking about some of the oral agents that we provide for metastatic hormone receptor positive breast cancer that require some more frequent blood work and labs and seeing what if we could delay that if we were able to implement initial endocrine therapy. So overall I think that everyone was trying to think of ways to keep our patients as safe as possible. And there were quite a few institutions and organizations that gathered, like minded individuals to be able to come up with these guidances.

DR. HELEN CHEW: Thank you both. Dr. Choueiri, in the upcoming months as the vaccination rolls out, do you think you will start reverting to pre-pandemic patient management at your institution?

DR. TONI CHOUEIRI: Oh, thank you for your question. Actually, I mean the short answer is I don't know. I think it's hard to say who is in control. I know who is in control. The virus is in control. Yes, there are a lot of signs, positive signs, happening, but we don't know what later on things going to happen. I personally think that stuff won't go back to normal immediately.

First, we can't expect everyone, all our patients, to be vaccinated despite our recommendation. Second, I would think that some folks are comfortable doing what they learned and they still want to have a mixed telemedicine. I'm talking not just physician but patient. They want a mix of telemedicine, face to face, and we have to see what's the implication of that is. There are some implications, of course, for out-of-state consult if patients have licenses there. There are indication on billing perhaps, although some preliminary data shows that this is going well.

What I want to say is some silver lining, hopefully, that our clinical operation and our clinical trials operation could be a bit more efficient after we learned how to be overall more efficient. We recently wrote with Doctor [INAUDIBLE], a German oncology, a piece about that. I think there will be a transition. The good thing is that there are processes, safety processes, best practices now that we know very well that we didn't know at the beginning of the pandemic, and that actually is reflected by a study we did in the Mass General Brigham Health Care System where we looked at the screening for cancer and compared the three months between March and June index case, the three months where we had the first pandemic, if you will, in the first peak, compared to three months prior, three months after, and three months into 2019. We saw, because of cancellation of a lot of elective procedure, we saw 80% decrease in screening.

But that picked up. It didn't pick up completely, but it did pick up because we have safety measures in place. So I think it will be a gradual increase, and we just have to learn as we go.

DR. HELEN CHEW: Thank you. Yes, it's certainly been a learning process. And I think some of the changes we've made are probably here to stay.

DR. OLIVER ENG: Yeah, I think the one thing that should not be forgotten is the impact on patients and their perception of delays, and it's very easy to think of this from an academic perspective of OK, it's safe to delay because of disease biology, and so and so and, make decisions based on the duration of therapy and so forth. But to call a patient, which all of us have had to do, to delay the therapy for a variety of reasons and explain why. I think it's something that we need to be cognizant of when we are making these decisions and really being transparent with the patients about the fact that we're taking consideration not only their risk but the risk to the community as well. And it's just made things a lot more complex. And time will tell as to the sort of sequelae of everything, all the decisions that are made in this period.

DR. TONI CHOUEIRI: I like that Oliver. I think that's very sensible honestly. I think there's wording. Sometimes it's not from us, it's the patient who want to delay. But I think the word delay does have some negative connotations, and actually, funny enough, when we did our paper in Journal of Oncology about screening, which went down, then up, and compared this, a reporter asked me directly, he said look, these patients were delayed. Did you missed the diagnosis?

And you can't-- it's just a bit, so the word we used is kind of postponed. I think despite it is a bit the same, but I think it looks-- because delay is negative. Delay implicates that we're missing something while it's mostly postponing some things that normally maybe you would this is not BEP for testicular cancer that you would anyhow want to delay, but this is postponed. So this was very sensible, and I agree with you.

DR. HELEN CHEW: Thank you. So that is all we have time for today. Thank you all for your time to share your valuable perspectives. For listeners that want more, look out for upcoming episodes in ASCO's eLearning series on COVID-19's continually evolving impact on cancer care.

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