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Alicia Morgans: Hi, my name is Alicia Morgans, a Geomedical oncologist and associate professor of medicine at Northwestern University in Chicago. I'm so excited to have you here with me today, Dr. Elena Castro, who is a friend and colleague, as well as being a consultant medical oncologist and the lead of the Geotranslational Unit at [inaudible] Victoria in Malaga. Spain. Thank you so much for being here with me today Dr. Castro.

Elena Castro: My pleasure.

Alicia Morgans: Wonderful. So, Elena, I had wanted to follow up with you after our last conversation on how the COVID-19 pandemic is really hitting Spain. And I so appreciate your time and sharing your experiences as both a clinician and a researcher living through this very challenging experience. Can you tell us how things are going for you in your clinics and what changes are happening to try to deal with this ongoing pandemic?

Elena Castro: Yes Alicia, I believe that when we spoke last time, we were in the middle of the pandemic, and as you say we have been hit very severely by the disease. The hospitals were collapsed with the number of cases. We have to change our clinical practice, and it has also posed a very big challenge for the Spanish society as well.

Fortunately, at present, the number of cases have come down significantly. We were in lockdown until mid-June. And we reached a plateau the number of cases and beds. Fortunately, the measures were eased. It's been a very strange situation anyway because there's a part of the population who are very afraid of contracting the virus with mostly the elderly people and... Don't live in their homes at all and the younger part of the society probably less concerned about the virus. So, at present what we are seeing is a rise in the number of cases, particularly affecting younger people.

Alicia Morgans: I think that's something that seems to be happening in many parts of the world, certainly here in the United States. And, ultimately it can lead to older people being infected and certainly our cancer patients. What are you doing in clinic to try to protect your patients? Have you... Are you doing things like telephone visits still, or are you changing your treatment plans or decisions around that? To try to keep those elderly patients that we both see with prostate cancer or potentially ill patients with things like bladder cancer safe during this time?

Elena Castro: No, at present we have restarted all our face-to-face visits. But we are keeping in mind that probably during... from September or October, we will have to go back to telephone-in clinics because a second wave of cases is expected and we may have to go back to that.
So, one of the things that we have then at hospital is that patients have to come to the clinics by their own. They cannot be with any relatives or with no one, which in Spain is something very uncommon because usually, the patients come to clinic either with friends or relatives or someone to accompany them.

No patient can be admitted in the hospital without the negative PCR test. And if the test is positive... obviously if they will have positive test, they can also be admitted. But then they have two different wings in the hospital and for patients who are positive and for patients who are negative.

We have tried to reduce the number of chemotherapies as much as possible. And whenever it was possible, we have used other therapies such as androgen receptors signaling inhibitors. Or, if we have started chemotherapy, then we have tried to use supportive therapies to try to diminish the chances of neutropenia or the complications that may require admission to the hospital.

Alicia Morgans: Are you finding that many of your patients have ended up being admitted either before, when we were more in the height of things, or even now as we're continuing to deal with the pandemic?

Elena Castro: No. And I have to say that none of our prostate cancer patients have been admitted to hospital, which is more or less... We were expecting a very high incidence of prostate cancer in these patient charts because of their age. But it's true that none of them had to be admitted. There's all these studies going on where maybe the inhibition of the androgen receptor, may be playing a role in the... And then this could be one of the reasons why these patients have been less affected because, for bladder cancer patients, it's true, that we have had several cases that have to be admitted and unfortunately some of them passed away.

Alicia Morgans: That's... and I'm very sorry to hear that about your patients with bladder cancer. And I hope that things improve now that we are more familiar with how to deal with these patients. But it is also very interesting that even though prostate cancer is such a common illness in men, that none of them have actually had to be admitted to the hospital. And I have to say for my part, there actually have not really been COVID admissions for our prostate cancer patients either. Sometimes they have admissions related to progression of disease or other complications from their cancer, but they've all actually been COVID negative and none have actually had any complications related to COVID.

So that is interesting. And I know that it is something that is being studied in several research projects to see whether there is an association there and whether some of the therapies that we use to suppress prostate cancer may also help patients not get COVID or get SARS-COV2.

So I also wonder in terms of clinical research, how has that moved forward in your experience, in terms of clinical research and laboratory research? I know you're so involved in that space, has that been affected? Is it still affected? I know it was affected earlier.

Elena Castro: Yes, for clinical trials, the sponsor recommended to stop recruitment during the worst months of the pandemic in our country. Now that is open again and we have continued to enroll patients, and we have continued with their follow-ups and tests. And now, at the moment we are running as normal. For research, the research centers were closed. And the number of people that are allowed to work in the research center is... The capacity is about 30%. Now it has been raised to 50%.

The research community is very frustrated because scientists should be considered principle work and they should be back at their other work like anyone else. I believe the only way to fight this disease or any other disease is with research. So it doesn't make much sense to keep these people away from their work.

Alicia Morgans: I think that's such a really important and interesting point to think about scientists who are fighting cancer and fighting other illnesses as being essential workers or principle workers. I think it absolutely makes sense, especially since many of them are used to wearing protective equipment for the work that they're doing, including things like face shields in many cases and masks, and they can still do their work with protective equipment.

So, I hope that that continues to evolve because I think we all recognize that the virus doesn't seem to be going away anytime in the very near future. So, we are going to need to continue to advance science while all of this is happening. And I know that we've all actually learned quite a bit as this has affected us.

And hopefully, those skills can help keep us safe as we do things like work in a laboratory. So if you had to give a piece of advice or something that you have learned from going through this experience, either to other clinicians and researchers or to patients, what would you say that you really learned and have taken away, and how will that hopefully help you as you deal with what may be a second wave in the coming months?

Elena Castro: Just what you said Alicia, that this virus is not going to go... It's not going to leave immediately. So, we need to keep alert. We cannot forget to wear our masks, to wash our hands, to keep distance with other people. But at the same time, we need also to resume our life. So we need to go out. We need to do our shopping, go to the hospital if we are told to go to the clinic, and visit your doctor. It's safe.
If at some point it is not safe, they will contact you by phone or anything. But we need to assume that it's going to be like this for a while. And just... Not be too concerned, but be aware. Be aware all the time.

Alicia Morgans: I think that's great advice to be cautious, to be aware, but to make sure that we don't put off medical visits that are necessary, that we don't put off the screening and diagnostics that will help us understand if we do have a medical problem if that could be related to a cancer that does need to be treated. And to get the treatments that we'd know we need to deal with the cancer that is here now. And to recognize the risk of the virus, but to take precautions as we have learned how to do and to move forward because we don't really have another choice at this point. We have to move forward. So, as we wrap up, that was a wonderful piece of advice. What would you say your message to patients, to clinicians would be if you have one to help them as they continue to go through this?

Elena Castro: To finish, is that we also have to be very aware of this, to take a lot of care of ourselves because to take care of our patients and care of someone else, we need to take care of us. So don't forget about that. Sometimes, I don't know, in other places, but in Spain for a while, the protocols were not very clear.

Things at the beginning were very messy and change from one time to another. We haven't had protective equipment all the time, but I think this is something that we must have in order to be able to take care of others. And I don't know, it's just... I believe we are doing very important work. Just keep doing that... and I don't know.

Alicia Morgans: I think though that's a great message to take care of ourselves while we take care of others, to certainly protect ourselves when we are in the clinic. Because as you said, it is very important work, but to also take care of ourselves when we're not in the clinic, to take time to decompress or to talk about our experiences with others in our families or our friends to try to do things that make us happy, that also keep us safe, of course.

And to keep ourselves both physically safe and mentally well at the same time is a wonderfully important message and a good one as we continue to go through this. And I wish that you take care of yourself physically and emotionally, and I so appreciate you taking the time to talk today.

Elena Castro: Thank you, Alicia.