Immediate Impact of COVID-19 on Cancer Care at Major Institutions

Dr. Grothey: In my practice, it’s interesting because we always think about delaying elective procedures. You don’t need your hip replacement right now, you can get it, let’s say in six months from now, or even dental cleaning, you know. There are certain procedures that we can delay, but cancer doesn’t always wait. If you have an aggressive malignancy that a patient has and we need to treat this malignancy, that’s more important than the hypothetical risk of infection. So, we are currently treating patients with chemotherapy. It’s not as crowded, let’s say, as before, and we’re trying to shift patients to some telemedicine, routine follow-up patients to limit exposure in the way you said, waiting room is not crowded, etc., but some patients are continuing on therapy, you know, actually a lot of patients, and there is some concern.

And as you said, I really believe we do not know exactly what’s going on. There are some reports from China that the mortality with cancer and COVID infection is higher, but we don’t know anything about risk. We think the immunotherapy issue is a very important one, especially since we already know some of the immunotherapy drugs can cause pneumonitis, which seems to be one of the important cytokine storm issues that really is associated with a high lethality in cancer patients once they go through the infection, etc.

So, how is Vanderbilt, your institution, handling this whole epidemic right now? I mean, how are you trying to move patients around, limit exposure, probably telemedicine approaches, etc.?

Dr. Warner: Yeah. Well, I’ll say a couple of things, but first I’ll say that one of my longer-term... so this is like the new full-time job, right, is addressing COVID-19. One of my longer-term research interests is formalizing the representation of chemotherapy regimens and their details, which has been actually lacking from medical records and other databases for decades, and we’re moving forward on that. Part of my long-term goal is to understand the impacts of treatment delays and dose reductions, and we actually don’t know as a community, because we haven’t been able to capture that granular data, Does delaying a cycle that’s supposed to be every three weeks to every four weeks, does that have an impact or is that okay? Does reducing a dose a little bit to try to reduce the neutropenia? You know, is that going to be okay? We’re not going to be able to answer those questions right away, but anyway, that’s one of my longer-term interests.

Dr. Grothey: So, learning from the COVID epidemic to really see beyond just the viral interaction?

Dr. Warner: I think we might. I think we might, because the impacts on the healthcare system are severe already, and so just speaking about Vanderbilt, first of all, our directives are changing daily, so what I say now might not be true later, but we’ve addressed some challenges of distance medicine head-on.

You know, we’re a state that’s long and skinny, right, and you’re actually at the edge of the state, but we have a seven-state catchment area where many of our patients come from. Many of our patients are coming from Kentucky for cancer care, and so you know, when the telemedicine started a week or two ago, we couldn’t provide care to those patients because of the federal restrictions on licensing, medical licensing. Now, that’s changed rapidly. Most of our clinicians are in the process of getting temporary licenses for our neighboring states so that we can provide telehealth. So the telehealth visits have increased exponentially, but we can’t forget that telehealth doesn’t really work for people who might not have the internet, you know, might not be savvy about computers, and unfortunately it will worsen certain disparities, but it’s clearly what we have to do.

We’re delaying elective procedures, as you said, just like most folks, and what’s elective and what isn’t? That’s subject to discussion. Is a curative cancer surgery for something that’s not otherwise immediately causing any symptoms, like a localized breast cancer picked up on a mammogram? Is that elective? Technically, I think it is, but it’s certainly very distressing, I think, for an individual to have a potentially curative cancer that they need to basically keep in place until things get a little bit stable.

And then you know, the other unfortunate impact of this has been on our clinical trial endeavors. You know, we’re not the only institution that has made this decision, but as of yesterday, we have shut down new approvals to clinical trials. We’re obviously continuing to treat patients who are already enrolled or who are in the enrollment process, but due to staffing and a host of other factors, we had to make that very tough decision yesterday.

Dr. Grothey: Yeah. That’s something we discussed actually on a SWOG call too, the Southwest Oncology Group call, earlier this week, that a lot of institutions have really shut down, and wisely shut down new trial approval, and it’s going to really have a huge impact on our research system right now beyond everything we’re talking about.