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Live Notes and Conference Coverage in Real Time. COVID19 And The Impact on Cancer Patients Town Hall with Leading Oncologists; April 4, 2020

Reporter: Stephen J. Williams, PhD 

@StephenJWillia2

UPDATED 5/11/2020 see below

This update is the video from the COVID-19 Series 4.

UPDATED 4/08/2020 see below

The Second in a Series of Virtual Town Halls with Leading Oncologist on Cancer Patient Care during COVID-19 Pandemic: What you need to know

The second virtual Town Hall with Leading International Oncologist, discussing the impact that the worldwide COVID-19 outbreak has on cancer care and patient care issues will be held this Saturday April 4, 2020.  This Town Hall Series is led by Dr. Roy Herbst and Dr. Hossain Borghaei who will present a panel of experts to discuss issues pertaining to oncology practice as well as addressing physicians and patients concerns surrounding the risk COVID-19 presents to cancer care.  Some speakers on the panel represent oncologist from France and Italy, and will give their views of the situation in these countries.

Speakers include:

Roy S. Herbst, MD, PhD, Ensign Professor of Medicine (Medical Oncology) and Professor of Pharmacology; Chief of Medical Oncology, Yale Cancer Center and Smilow Cancer Hospital; Associate Cancer Center Director for Translational Research, Yale Cancer Center

Hossain Borghaei, DO, MS , Chief of Thoracic Medical Oncology and Director of Lung Cancer Risk Assessment, Fox Chase Cancer Center

Giuseppe Curigliano, MD, PhD, University of Milan and Head of Phase I Division at IEO, European Institute of Oncology

Paolo Ascierto, MD National Tumor Institute Fondazione G. Pascale, Medical oncologist from National Cancer Institute of Naples, Italy

Fabrice Barlesi, MD, PhD, Thoracic oncologist Cofounder Marseille Immunopole Coordinator #ThePioneeRproject, Institut Gustave Roussy

Jack West, MD, Department of Medical Oncology & Therapeutics Research, City of Hope California

Rohit Kumar, MD Department of Medicine, Section of Pulmonary Medicine, Fox Chase Cancer Center

Christopher Manley, MD Director, Interventional Pulmonology Fox Chase Cancer Center

Hope Rugo, MD FASCO Division of Hematology and Oncology, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center

Harriet Kluger, MD Professor of Medicine (Medical Oncology); Director, Yale SPORE in Skin Cancer, Yale Cancer Center

Marianne J. Davies, DNP, MSN, RN, APRN, CNS-BC, ACNP-BC, AOCNP Assistant Professor of Nursing, Yale University

Barbara Burtness, MD Professor of Medicine (Medical Oncology);  Head and Neck Cancers Program, Yale University

@pharma_BI and @StephenJWillia2 will be Tweeting out live notes using #CancerCareandCOVID19

Live Notes

Part I: Practice Management

Dr. Jack West from City of Hope talked about telemedicine:  Coordination of the patient experience, which used to be face to face now moved to a telemedicine alternative.  For example a patient doing well on personalized therapy, many patients are well suited for a telemedicine experience.  A benefit for both patient and physician.

Dr. Rohit Kumar: In small cancer hospitals, can be a bit difficult to determine which patient needs to come in and which do not.  For outpatients testing for COVID is becoming very pertinent as these tests need to come back faster than it is currently.  For inpatients the issue is personal protection equipment.  They are starting to reuse masks after sterilization with dry heat.   Best to restructure the system of seeing patients and scheduling procedures.

Dr. Christopher Manley: hypoxia was an issue for COVID19 patients but seeing GI symptoms in 5% of patients.  Nebulizers have potential to aerosolize.  For patients in surgery prep room surgical masks are fine.  Ventilating these patients are a challenge as hypoxia a problem.  Myocarditis is a problem in some patients.  Diffuse encephalopathy and kidney problems are being seen. So Interleukin 6 (IL6) inhibitors are being used to reduce the cytokine storm presented in patients suffering from COVID19.

Dr. Hope Rugo from UCSF: Breast cancer treatment during this pandemic has been challenging, even though they don’t use too much immuno-suppressive drugs.  How we decide on timing of therapy and future visits is crucial.  For early stage breast cancer, neoadjuvant therapy is being used to delay surgeries.  Endocrine therapy is more often being used. In patients that need chemotherapy, they are using growth factor therapy according to current guidelines.  Although that growth factor therapy might antagonize some lung problems, there is less need for multiple visits.

For metastatic breast cancer,  high risk ER positive are receiving endocrine therapy and using telemedicine for followups.  For chemotherapy they are trying to reduce the schedules or frequency it is given. Clinical trials have been put on hold, mostly pharmokinetic studies are hard to carry out unless patients can come in, so as they are limiting patient visits they are putting these type of clinical studies on hold.

Dr. Harriet Kluger:  Melanoma community of oncologists gathered together two weeks ago to discuss guidelines and best practices during this pandemic.   The discussed that there is a lack of data on immunotherapy long term benefit and don’t know the effectiveness of neoadjuvant therapy.  She noted that many patients on BRAF inhibitors like Taflinar (dabrafenib)   or Zelboraf (vemurafenib) might get fevers as a side effect from these inhibitors and telling them to just monitor themselves and get tested if they want. Yale has also instituted a practice that, if a patient tests positive for COVID19, Yale wants 24 hours between the next patient visit to limit spread and decontaminate.

Marianne Davies:  Blood work is now being done at satellite sites to limit number of in person visits to Yale.  Usually they did biopsies to determine resistance to therapy but now relying on liquid biopsies (if insurance isn’t covering it they are working with patient to assist).  For mesothelioma they are dropping chemotherapy that is very immunosuppressive and going with maintenance pembrolizumab (Keytruda).  It is challenging in that COPD mimics the symptoms of COVID and patients are finding it difficult to get nebulizers at the pharmacy because of shortages; these patients that develop COPD are also worried they will not get the respirators they need because of rationing.

Dr. Barbara Burtness: Head and neck cancer.  Dr. Burtness stresses to patients that the survival rate now for HPV positive head and neck is much better and leaves patients with extra information on their individual cancers.  She also noted a registry or database that is being formed to track data on COVID in patients undergoing surgery  and can be found here at https://globalsurg.org/covidsurg/

Dr. Burtness had noted that healthcare care workers are at high risk of COVID exposure during ear nose and throat (ENT) procedures as the coronavirus resides in the upper respiratory tract.  As for therapy for head and neck cancers, they are staying away from high dose cisplatin because of the nephrotoxicity seen with high dose cisplatin.  An alternative is carboplatin which generally you do not see nephrotoxicity as an adverse event (a weekly carboplatin).  Changing or increasing dose schedule (like 6 weeks Keytruda) helps reduce immunologic problems related to immunosupression and patients do not have to come in as often.

Italy and France

Dr. Paolo Ascierto:   with braf inhibitors, using in tablet form so patients can take from home.  Also they are moving chemo schedules for inpatients so longer dosing schedules.  Fever still a side effect from braf inhibitors and they require a swab to be performed to ascertain patient is COVID19 negative.  Also seeing pneumonitis as this is an adverse event from checkpoint inhibitors so looking at CT scans and nasal swab to determine if just side effect of I/O drugs or a COVID19 case.  He mentioned that their area is now doing okay with resources.

Dr. Guiseppe Curigliano mentioned about the redesign of the Italian health system with spokes and hubs of health care.  Spokes are generalized medicine while the hubs represent more specialized centers like CV hubs or cancer hubs.  So for instance, if a melanoma patient in a spoke area with COVID cases they will be referred to a hub.  He says they are doing better in his area

In the question and answer period, Dr. West mentioned that they are relaxing many HIPAA regulations concerning telemedicine.  There is a website on the Centers for Connective Health Policy that shows state by state policy on conducting telemedicine.   On immuno oncology therapy, many in the panel had many questions concerning the long term risk to COVID associated with this type of therapy.  Fabrice mentioned they try to postpone use of I/O and although Dr. Kluger said there was an idea floating around that PD1/PDL1 inhibitors could be used as a prophylactic agent more data was needed.

Please revisit this page as the recording of this Town Hall will be made available next week.

UPDATED 4/08/2020

Below find the LIVE RECORDING and TAKEAWAYS by the speakers

Town Hall Takeaways

Utilize Telehealth to Its Fullest Benefit   ·       Patients doing well on targeted therapy or routine surveillance are well suited to telemedicine ·       Most patients are amenable to this, as it is more convenient for them and minimizes their exposure ·       A patient can speak to multiple specialists with an ease that was not previously possible ·       CMS has relaxed some rules to accommodate telehealth, though private insurers have not moved as quickly, and the Center for Connected Health Policy maintains a repository of current state-by-state regulations:  https://www.cchpca.org/   Practice Management Strategies   ·       In the face of PPE shortages, N95 masks can be decontaminated using UV light, hydrogen peroxide, or autoclaving with dry heat; the masks can be returned to the original user until the masks are no longer suitable for use ·       For blood work or scans, the use of external satellite facilities should be explored ·       Keep pumps outside of the room so nurses can attend to them quickly ·       Limit the use of nebulizers, CPAPs, and BiPAPs due to risk of aerosolization   Pool Our Knowledge for Care of COVID Patients   ·       There is now a global registry for tracking surgeries in COVID-positive cancer patients:  https://globalsurg.org/cancercovidsurg/ ·       Caution is urged in the presence of cardiac complications, as ventilated patients may appear to improve, only to suffer severe myocarditis and cardiac arrest following extubation ·       When the decision is made to intubate, intubate quickly, as less invasive methods result in aerosolization and increased risks to staff   Study the Lessons of Europe   ·       The health care system in Italy has been reorganized into “spokes” and “hubs,” with a number of cancer hubs; if there is a cancer patient in a spoke hospital with many COVID patients, this patient may be referred to a hub hospital ·       Postpone adjuvant treatments whenever possible ·       Oral therapies, which can be managed at home, are preferred over therapies that must be administered in a healthcare setting ·       Pneumonitis patients without fevers may be treated with steroids, but nasal swab testing is needed in the presence of concomitant fever ·       Any staff who are not needed on site should be working from home, and rotating schedules can be used to keep people healthy ·       Devise an annual epidemic control plan now that we have new lessons from COVID   We Must Be Advocates for Our Cancer Patients   ·       Be proactive with other healthcare providers on behalf of patients with a good prognosis ·       Consider writing letters for cancer patients for inclusion into their chart, or addendums on notes, then encourage patients to print these out, or give it to them during their visit ·       The potential exists for a patient to be physiologically stable on a ventilator, but intolerant of decannulation; early discussions are necessary to determine reasonable expectations of care ·       Be sure to anticipate a second wave of patients, comprised of cancer patients for whom treatments and surgery have been delayed!   Tumor-Specific Learnings   Ø  Strategies in Breast Cancer: ·       In patients with early-stage disease, promote the use of neoadjuvant therapy where possible to delay the need for surgery ·       For patients with metastatic disease in the palliative setting, transition to less frequent chemotherapy dosing if possible ·       While growth factors may pose a risk in interstitial lung disease, new guidelines are emerging   Ø  Strategies in Melanoma: ·       The melanoma community has released specific recommendations for treatment during the pandemic:  https://www.nccn.org/covid-19/pdf/Melanoma.pdf ·       The use of BRAF/MEK inhibitors can cause fevers that are drug-related, and access to an alternate clinic where patients can be assessed is a useful resource   Ø  Strategies in Lung Cancer: ·       For patients who are stable on an oral, targeted therapy, telehealth check-in is a good option ·       For patients who progress on targeted therapies, increased use of liquid biopsies when appropriate can minimize use of bronchoscopy suites and other resources ·       For patients on pembrolizumab monotherapy, consider switching to a six-week dosing of 400 mg ·       Many lung cancer patients worry about “discrimination” should they develop a COVID infection; it is important to support patients and help manage expectations and concerns

UPDATED 5/11/2020

Townhall on COVID-19 and Cancer Care with Leading Oncologists Series 4

Addressing the Challenges of Cancer Care in the Community