Balancing the Risk of Delaying GU Cancer Treatments with the Risk of COVID-19 – Pedro Barata
May 8, 2020
Joining Alicia Morgans is Pedro Barata from Tulane University in New Orleans, Louisiana to discuss the difficulties of balancing the risk of COVID-19 with the risk of delaying systematic therapies in one of the United State’s hotspots. Dr. Barata distinguishes differences in managing prostate, kidney, and bladder cancer care in this current healthcare setting.
Pedro C. Barata, MD, MSc, Assistant Professor of Medicine, Hematology & Medical Oncology, Tulane University, New Orleans, Louisiana
Alicia Morgans, MD, MPH Associate Professor of Medicine in the Division of Hematology/Oncology at the Northwestern University Feinberg School of Medicine in Chicago, Illinois.
View: COVID-19 and Genitourinary Cancers Videos
Alicia Morgans: Hi, my name is Alicia Morgans and I'm a GU medical oncologist and Associate Professor at Northwestern University in Chicago, Illinois. I am so excited to have here with me today, a friend and colleague, Dr. Pedro Barata, who's an Assistant Professor of Medicine and a GU medical oncologist at Tulane University in New Orleans, Louisiana. Thank you so much for being here today.
Pedro Barata: Thank you so much, Alicia. What a pleasure to be here and to have this opportunity to share the reality in New Orleans.
Alicia Morgans: Wonderful. So, Pedro, we were talking just briefly before we started recording and I'd love to capture that on tape, your experience in day-to-day clinical practice in New Orleans that we all know has been hit very hard actually by COVID-19. What are things like on a day-to-day basis for you?
Pedro Barata: Yeah, no, that's a great question. As you said, we all had to adjust and adapt, right? In general, I think the clinic volume went down by, just rough math, but probably 70+ percent. We're, of course, postponing all patients that don't necessarily need to see us right away. We have also been doing that for a lot of our... So, basically our clinic, just to give a little bit of background, basically prostate, kidney, and bladder cancers. So, for prostate cancer, most of our patients are on oral medications, novel hormonal therapies, abiraterone, enzalutamide, et cetera. So those, we have been really doing a lot of telemedicine, right? They get labs closer home when they need them and then we do FaceTime kind of appointments and we see them that way, and we get them in only when they are progressing or really need scans or any other reason. So, that's for the prostate for the most part.
Then, we have the bladder and the kidney cancer. Bladder cancer, I separate them. Those with the curative intent and those at the advanced stage. Those who need chemotherapy with curative intent, we really have a multidisciplinary discussion in terms of knowing that the benefit of neoadjuvant chemo is real, although small, in terms of survival benefit. A few cases because the surgeons could not get them to the OR because of COVID, we actually are offering neoadjuvant chemo for that reason because it allows us to postpone the surgical moment a little bit longer, and at the same time, we are giving them a curative treatment.
But for that, because we had a fairly good number of patients on IV treatments, one of the things we did here at the cancer center is testing everybody, so all patients getting IV therapies are getting the COVID test, which is a qualitative test. It's a yes or no, and a positive comes back in five minutes, a negative comes back in around 15 minutes. So, that's one. On top of social distancing, everybody's wearing a mask. I think we have, for the most part... We had two cases in the last three weeks of COVID positive, and so I think for the most part we had a COVID-19-free environment here at the cancer center.
But, as I was saying that's basically for bladder in the metastatic setting, depending on how quickly do we need to start treatment. A few cases we can postpone a few months, other on immunotherapy instead of doing every three weeks, for instance, I'm thinking of pembrolizumab. In some cases, we have been pushing them a little bit longer. And then, for kidney cancer, we basically treat patients with advanced renal cell carcinoma. In the last two years or so, we've been treating from the oral therapies to the combination of immunotherapy ipi/nivo or a combo of immunotherapy and VEGF, axi/pembro for the most part.
So, in some situations, we have been starting on the oral angiogenic drug and then wait for this COVID wave to go away to get them on immunotherapy. In other cases, we have been doing them both, but again, postponing the frequency or delaying the frequency of the PD-1 inhibitor in this setting. So, there's a lot of changes, right? We had to adapt. I'm just thinking, going back to renal cell carcinoma but in the neoadjuvant setting, we happen to have a study which is a cooperative group study, and that basically offers neoadjuvant immunotherapy prior to surgery. So, due to COVID, a lot of our surgeons cannot go to the OR, because of the restrictions in place. So really, one option would be to enroll these patients on a trial, allow them to get neoadjuvant therapy, which is not standard of care, but on study we do it, and then is another opportunity to postpone the date of surgery a bit longer. So, there are ways to navigate these waters, but it's definitely impacting the way we are dealing with these patients these days.
Alicia Morgans: I completely agree. I think it's really interesting to think about kidney cancer as an example of how we're making choices that are actually good ones for patients. You can't really go wrong when we have multiple options for patients, but we're making decisions that we think will hopefully reduce the number of visits to clinic for example, or perhaps the avoidance of more complex therapies that may require more lab work or more in-person type visits. So, I think that's something that certainly is pervasive and is going to be a good thing.
I love that you are hopefully moving though towards a new normal where you're going to be able to continue to test your patients so that when you do see you can have those rapid tests maybe and hopefully be able to make choices in real-time or very close to real-time about treatments that may be more challenging, but when we don't have the choice anymore to avoid or to delay certain treatments that we will still have the opportunity to use them.
One of the other things I wanted to ask about too was surgery in kidney cancer. We are in the setting of metastatic disease for patients with really advanced disease or moderately advanced disease at least, trying to avoid a nephrectomy in most patients based on the CARMENA trial or many of us are, is this something that you are doing in your center, or are you still doing a lot of palliative nephrectomies or nephrectomies in the setting of metastatic disease?
Pedro Barata: Yeah, no, that's a great question, Alicia. So, indeed the bulk nephrectomies, if we take COVID out of the picture has been a great option for a selected group of patients, and I think it's supported by CARMENA data, and so we do consider that. In the context of COVID, the bulk nephrectomy is not considered immersion procedure so it's not a patient I could send right away. But, we do have a fair number of cases where the bulk nephrectomy was not done upfront, but it was done after a patient is started on a backbone immunotherapy regimen and is on cruise control, and has a good PR if you will, then most of the disease is in the kidney with a primary tumor in place. Those are patients where we still consider for a cytoreductive nephrectomy a little bit after initiation of systemic treatment. So, if there's a patient where they might be a good option for surgery but we cannot do it due to COVID, and we start him, and it's a patient where the disease is moving and they will need systemic treatment sooner rather than later, so we do the other way around, right? We start them on systemic treatment and then we revisit the decision to do cytoreductive nephrectomy. And if we can't do it in three, four, six months, we definitely going to consider that.
Alicia Morgans: Great, and I think we are going to have to start thinking about what we do and where we go in the upcoming months for all of us at all of our centers as one wave hopefully is moving past us and we hopefully ride that tide before we get to the next one. Just wondering, do you have any overarching message or I guess overall lesson that you've learned from the last few weeks dealing with COVID-19 and one of the hotspots in the United States?
Pedro Barata: Yeah, I mean, a lot of thoughts. I know a lot of the thoughts that I have might be regional, right? Regional implications. So, what might be true in Louisiana and work really well here in Louisiana, might not work exactly the same way in other states. I do think that unfortunately, the patients that we treat, a lot of them really need us, and mortality is a reality, right? Patients die from advanced prostate, advanced kidney, advanced bladder cancer, so I think it's very, very important for us to weigh the risk of COVID on one end, but on the other end weigh the risk of delaying systemic therapies. Because I mean, the risk of COVID is real, but the risk of progressing and dying from the cancers we treat is also very, very real.
So, I think that balance is very hard to get. And in a lot of times, there's not a white or black answer, if you will. But, I think that is important for a patient that we have in front of us to think what's the benefit of getting him as far as we can from coming to these major institutions, from the major cities where the number of COVID-19 is high versus delaying a treatment that potentially can help them. So, I think that balance is difficult. We are all facing that problem. There are different ways of dealing with this, so one thing that I do and maybe my word of advice I guess is whenever we don't know, it's okay not to know. I usually touch base with mentors, friends, and ask them, "Hey, what would you do? I have this case, so and so, what are your thoughts?" By doing that, I think we're more likely to get an answer that helps our patients.
Alicia Morgans: I completely agree and certainly I know just last night I got an email from my friend and mentor, Maha Hussain, asking other colleagues, "What would you do in this situation?" We all need to remember that it is always okay to phone or email a friend, we're all in this together, and nobody knows what truth is, we're all just trying to make our best guess.
Pedro Barata: Exactly.
Alicia Morgans: So, doing the best for our patients and trying to understand the risk of the cancer in the context of a theoretical risk of COVID is hard. And I appreciate that you're bringing that to the table. But, thank you so much for your time and your insights today, Dr. Barata. I wish you safety and good health and lots of luck as we move forward.
Pedro Barata: No, thank you so much for having me, and stay safe, Alicia, it's very important. We need you as we need all our colleagues. We need the healthcare teams to be healthy, to take care of our patients. So, thank you very much.
Alicia Morgans: Thank you.