Our Response to Caring for Cancer Patients during the COVID-19 Pandemic

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest, innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic, overseeing our Taussig phase one and sarcoma programs.

Today I'm happy to welcome Dr. Matt Kalaycio, vice chair of Cleveland Clinic's Taussig Cancer Institute to discuss how managing cancer patients during the coronavirus pandemic poses a variety of challenges for oncologists. So welcome Matt.

Matt Kalaycio, MD: Thanks, Dale. It's great to be here.

Dale Shepard, MD, PhD: Maybe you can tell us a little bit about what you do here at Cleveland Clinic.

Matt Kalaycio, MD: I am currently the vice chairman of the Taussig Cancer Institute at the Cleveland Clinic. I was formerly chairman of the Department of Hematology and Medical Oncology, and I've been at the Clinic since 1991. So I've got a lot of history here. Maybe because of that and those experiences, when the pandemic became widely noticed and we realized that we had to develop an effective response to it, I started to lead the Cancer Institute's response to the pandemic with regard to how to protect not only our caregivers, but our patients during this time.

Dale Shepard, MD, PhD: So what would you say are some of the biggest changes we've had to make logistically in terms of getting patients in and safely treated?

Matt Kalaycio, MD: Well, it's evolved over time. In the beginning, we were all worried about being overwhelmed with the number of patients. So the first thing we had to do was make room in the hospital for what we thought was going to be a surge. So we converted as many of our inpatient regimens to outpatient regimens as possible. That meant delaying in some cases elective procedures and things like I guess transplants for multiple myeloma and some surgical procedures.

But worst of all, we had to delay a lot of screening like mammograms and colonoscopies while we were preparing for this surge. It also led to a lot of transference of care from the clinic to electronic means, televisits and such, either by phone or by virtual visits using various vendors.

Finally, we had to adapt our cancer center to the realities of social distancing. So we had to screen everyone who came in the building. That meant limiting some of the entrances to the building with appropriate signage, so that patients and caregivers knew what six feet meant, and that we were trying our best to keep people at that six foot minimum. We limited the number of people in our elevators. We put shields up in front of some of our patient service representatives. We put hand sanitizers everywhere. Our environmental services team mobilized and cleaned more frequently and more diligently with regard to stability, and we all began to wear cloth masks to protect each other.

We also provided the appropriate personal protective equipment for our infusion nurses, who are very close to our patients who are getting treated. Not only did we do all these things at our main campus, we had to do it at all of our regional sites as well. So this was an enormous undertaking that has been I think effective in that none of our caregivers have been infected with COVID-19 at work that we know of. We think all the folks who have so far been infected have got their infection in the community, and that holds even true today.

Dale Shepard, MD, PhD: It certainly has been a fluid time in many, many ways. I remember a lot of our appointments became virtual. Like you said, we started changing what we're doing, and it seems like more people are coming to clinic. Does that seem to be the case across the Institute, that more people are actually venturing out and less afraid to come in for treatment?

Matt Kalaycio, MD: Certainly that's true. In the early stages in March, late March, April and early May, the number of patients in the cancer center was very small. Not only because the patients didn't want to come to see us, but we didn't want them to come here. We weren't set up, we weren't ready. The worry of community spread was very high at the time. So we purposely kept people out. As we successfully flatten the curve and the huge surge didn't really materialize, we began a staged reopening that coincided with the State of Ohio's phased in reopening. In June and now July, it's been gratifying to see that we are very nearly back to pre-pandemic patient volumes.

Dale Shepard, MD, PhD: So if you think about patients coming in, they're already scared that they have cancer and now they're coming in, and in many ways it was interesting that they were sometimes less worried about the cancer they knew they had and more worried about the virus they might get. What kind of guidance should we be giving patients about precautions, anything different than the general population, or what are your thoughts on how we help patients understand their risks?

Matt Kalaycio, MD: Yeah. So this is, of course, the question that just about every single patient is asking every single oncologist across the nation. What we've learned, and a lot of these data that I'm about to refer to were presented at the annual meeting of the American Society of Clinical Oncology (ASCO), which was a virtual meeting. For those of you who are ASCO members, this session on Coronavirus and cancer is still available on the internet, on the ASCO website. I think it's for free. You can watch this presentation. But these data confirmed what had been published and reported at other places, that cancer patients as a whole are not at any additional risk of getting COVID-19, but certain populations of cancer patients are at higher risk of severe COVID-19. So our recommendations for cancer patients are no different than from the general public with regard to disease risk mitigation. Cloth masks, social distancing, hand hygiene, staying home. That's good advice for everybody across the nation in order to prevent getting COVID-19.

The conversation becomes more nuanced when you start to talk about the implications of actually getting COVID-19 in a cancer patient.

Dale Shepard, MD, PhD: Makes sense. That's good advice. That's certainly something that's front and center. Patients also are oftentimes asking questions about returning to work, and their susceptibility from work. I'm guessing the guidance would be similar?

Matt Kalaycio, MD: That's correct. Our experience with caregivers returning to work is similar to guidance that is recommended across the nation for all workers. That is that someone who has been infected with COVID-19, whether symptomatic or not, from the day of their positive test to the time they can return to work is governed more by time than by additional testing.

So those patients who are infected can test positive for a prolonged period of time, even though they're not infectious. The current CDC guidelines suggest that time is more important. So we've used a 10 and three and 28 day rule. So the 10 day rule is that folks who are COVID positive 10 days from their positive test, and three days from their last symptom, are sufficiently noninfectious enough that they can return to work, as long as they wear a mask from that point forward, which they're going to do anyway.

For patients, they can come at that 10 and three day follow-up, but then we ask them also to wear a mask for at least 28 days. Now that was our original guidance. Now we mandate masks for everybody at all times. So that 28 day thing doesn't much matter anymore. But the important point is that patients, whether they have cancer or not, can return to either the cancer center or to work based on the time from infection, more so than any negative test that they may be exposed to afterwards.

Dale Shepard, MD, PhD: That's really important for people to realize because it seems like people have a cancer that needs treated and then they get tested positive, they have two problems, and we still need to move forward and treat the cancer. So how do you negotiate that? That's great guidance. Tell me a little bit about what we're doing in terms of testing for people who are coming in for procedures or treatment or things like that.

Matt Kalaycio, MD: Right, so this also has evolved as tests became more available. As you know, there are two general ways of testing. One's a rapid test and one's a slower test that's got a lower false negative rate. The rapid tests are used in an emergency setting. So someone comes to the emergency room, they need to be admitted. They'll do a rapid test just to make sure that they don't have COVID as something that's going on right now. And those results are available in a couple of hours. For elective admissions, and that's what most of oncology turns out to be, people who are coming into the hospital for chemotherapy or for a surgical procedure, then they are all being tested these days with the standard test, which takes about 24 hours to get results back.

At the Cleveland Clinic, we're getting results back, I just learned this morning, on average 10 hours after the test. So if you got tested within 72 hours of admission and you're negative, you're good to go for any procedure and any inpatient admission. As testing becomes more available, I'm sure that will get extended to procedures in the outpatient area as well. I mean, as far as chemotherapy and such, but we don't have the bandwidth to do that yet. It's not clear that it's even necessary to do that yet.

Dale Shepard, MD, PhD: That's good guidance because with the testing, there's a lot of confusion out there in terms of who gets tested and when. Sort of along those lines, we have the flu season coming up. We have patients who may develop symptoms from their cancer, they may have symptoms from their treatment. We're of course worried about them getting COVID. Upper respiratory infections, like colds and flus. How are we thinking ahead in terms of how to deal with what will probably be a large increase in patients with symptoms as we get into fall and winter?

Matt Kalaycio, MD: Yes, it will be a challenging time to say the least. What we're working on now, and the Cleveland Clinic has, if I'm not mistaken, developed its own internal way of doing this with patent pending, is to combine influenza A, B, RSV and COVID-19 into a single test, a single swab. I imagine that test will be what we'll be using for anybody with symptoms, as soon as that test becomes available. That should give us those patients who have treatable diseases, and in the case of COVID-19, particularly infectious ones, for appropriate triage and management from a single test.

But I think the increasing availability of appropriate tests that will distinguish these various possibilities will make our work a little easier as the COVID-19 pandemic continues, until such time as we have an effective vaccine.

Dale Shepard, MD, PhD: Yeah, that certainly sounds promising. So certainly here at the Cleveland Clinic, we see patients in our neighborhood, in our suburbs, but we see a lot of patients that come from around the state, from around the region, from around the world. How has COVID 19 and this pandemic changed how we approach our ability to see patients outside of our immediate area?

Matt Kalaycio, MD: For those folks who are coming from a distance, thankfully at this point, Ohio is not mandating quarantine for folks who are seeking healthcare. There was at one point a mandate for folks coming from New York that they would need to self-quarantine or not even come into the state, but that's never applied to those seeking healthcare in the state.

We've increased our ability to provide virtual consultations to those who are coming at a distance. I think that's probably the most important thing that we've managed to do for our patients who come at a distance. We still want those folks to consult with us, but in more and more cases we are doing that virtually and then working with local caregivers and providers to guide their treatment at a distance, rather than actually provide it here. Which becomes difficult when travel is anything more than a short car ride.

Dale Shepard, MD, PhD: Actually our ability to do telemedicine and ramp that up could ultimately be a win in terms of access?

Matt Kalaycio, MD: I think it will be in the future. My impression is that the pandemic will hasten the arrival of virtual medicine, both in urban centers and in rural locations, as we get more comfortable with the idea and the necessity of such technology. I think that we will have to adapt with the times, and those of us who are beholden to the hands on physical exam, will need to take account of reality and look into ways technology can expand our reach beyond our historically limited sense of geography.

Dale Shepard, MD, PhD: Makes sense. So you mentioned earlier that we were trying to actively keep as many people as possible out of the building, trying to maintain safety, certainly made good sense, but I think there's a general concern here that ultimately we may end up with a downstream effect of people showing up with late stage disease because of missed screening opportunities, for instance. I know I had a lot of patients who wanted to push out surveillance scans. Do we have any plans on how to recapture some of that lost opportunity?

Matt Kalaycio, MD: Well, I don't know that we have a specific plan to do so, so much that we are trying to spread the word that we are open and have been open to take care of patients with cancer. What we don't want, those who feel a lump or have a symptom, is to ignore it and put it off while they wait for the pandemic to subside because that's taking too long. As we've demonstrated here over and over again, the time it takes to start treatment of cancer is important in improving survival. So we want to stress to those who are listening to this podcast and to patients and to anyone we possibly can, it's as safe at our cancer center or any cancer center as it can be.

We have implemented everything we need to do to keep people safe. We've shown that it is safe, and we encourage and plead with patients and caregivers to send us those patients with cancer who we can help. We'll mitigate the concerns of the pandemic while doing our best to improve survival for these patients who can do so. It's unfortunate that right in the middle of a revolution in oncologic therapeutics, that a pandemic comes along that keeps patients from being able to avail themselves of that very revolution.

Studies have shown that these treatments do not impact the risk of COVID-19, and patients who are in remission have no more risk of severe COVID-19 than anybody else does, but having active disease does. So it's our mandate to not only identify patients with cancer, but to treat them into remission, to make them safe not only from the cancer, but from the pandemic.

Dale Shepard, MD, PhD: And that difficulty with them getting treatment of course applies to not only standard therapies, but also clinical trials.

Matt Kalaycio, MD: Absolutely. The NCI has had a dramatic reduction in the number of patient accruals to clinical trials. Often clinical trials represent the cutting edge treatment that cancer centers like us provide. The inability to participate in those trials challenges the entire nation with regard to additional advances in cancer treatment.

Dale Shepard, MD, PhD: Certainly this is a very, very fluid time, and there's been lots and lots of changes and there continue to be. As you look back and you think forward, what are you still most concerned about? What do we still really need to make the most improvements in terms of getting effective therapy to patients?

Matt Kalaycio, MD: Well, there's three things, if you consider that we need better treatments, we're not curing everybody with cancer. So oncologists are challenged to improve our treatments at every step along the way, whether there's a pandemic or not. But separate from that, we have to reassure our patients that it's safe for them to come and get treatment here. That staying home creates a bigger problem, and that we can manage the risks of COVID-19.

The other side of that is we have to do the same for the caregivers who are providing the care. A caregiver in the cancer center who doesn't feel safe either with patients or with their coworkers, is going to be a less effective provider of care than someone who is comfortable that when they're at work, they're as safe as they can possibly be. So I think those are the challenges that we have to face and overcome if we're ever going to manage the primary objective, which is to advance cancer cures.

Dale Shepard, MD, PhD: So certainly good direction moving forward. What do you think have been the biggest wins?

Matt Kalaycio, MD: I think the testing. We've been able to ramp up testing, so as we sit here speaking just about anybody who needs to can be tested. I think that creates a certain degree of safety. The other win is that because of all of our efforts, not just at the cancer center, but in Ohio in general and in the Cleveland Clinic in particular, we flattened that curve in March and we prevented a disaster such as what happened in New York at the time, and what's happening in Florida and Texas now.

Dale Shepard, MD, PhD: That certainly has been a huge benefit to us and our patients. Well, thanks a lot, Matt, do you have any additional comments?

Matt Kalaycio, MD: Oh, we need a vaccine.

Dale Shepard, MD, PhD: Oh yeah, that.

Matt Kalaycio, MD: I fear that we're in this for the long haul. I think it's false hope to say, "Don't worry about it. We'll put off your cancer treatment for a couple of months when all this is passed." I think that is the wrong way of thinking about this. I think we need to think about this as long term, and we need to manage it in real time, not plan for some panacea in the future.

Dale Shepard, MD, PhD: Well, that's certainly excellent insight you've given us here today, and thank you for joining.

Matt Kalaycio, MD: It was a pleasure. Thanks for having me.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. Don't forget you can access real time updates from Cleveland Clinic's Cancer Center experts on our ConsultQD website at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.