Safe and Effective Cancer Care During the COVID-19 Pandemic - Toni Choueiri

March 19, 2020

Date Recorded: March 19, 2020

Joining Alicia Morgans is Toni Choueiri to share the measures he is taking at his clinic to support safe and effective cancer care during the COVID-19 pandemic. Dr. Choueiri, the Director of the Lank Center for Genitourinary Oncology at the Dana-Farber Cancer Institute, shares that in addition to following strict screening processes, his team is working to prioritize or pause patient treatments who may be at risk of immunosuppression.


Toni K. Choueiri, MD, Jerome and Nancy Kohlberg Professor of Medicine, Harvard Medical School, Attending Physician, Solid Tumor Oncology, Dana-Farber Cancer Institute, Director, Genitourinary (GU) Oncology Disease, Center, Dana-Farber Cancer Institute, Director, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute

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.

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Alicia Morgans: Hi, I am so happy to have here with me today, Dr. Tony Choueiri, who is the Director of the Lank Center for Genitourinary Oncology at the Dana-Farber Cancer Institute also working with the Brigham Women's Hospital in Boston, Massachusetts. Thank you so much for being here with me today, Toni.

Toni Choueiri: Thank you, Alicia. And I hope you and your family and all your colleagues are safe at this time.

Alicia Morgans: Well, thank you for saying that and I hope the same for you and as we think about that and keeping people safe, I know we're both thinking also about our patients and I know as the Director of the GU Oncology Group at the Dana-Farber, you're thinking about that on a level of not just the patient, one by one, but really as a person who's directing an entire center. How are you thinking about and supporting patient care in your group and certainly the physicians that work within your group to make sure that we all do the best for our patients?

Toni Choueiri: Yeah. So we did actually, we had some changes to do, how we care for patients because I can tell you the Farber was able to move in a very short time, 3000 staff to work remotely. We believe very much in social distancing. So we're working most of us remotely, business as usual, but working remotely and we have constantly updated our clinical care in terms of a follow-up and in terms of patients, in terms of provider available in the clinic. Having said so the most important thing is how we are screening patients and what type of questions we are asking and this is a very dynamic process and the screening that we started, a process that we started a week ago, by screening patients by institute guidelines that were exposed to COVID-19 now expanded into screening anyone with symptoms such as symptoms that can happen with COVID-19 as well as other viral or even bacterial such as fever, cough, shortness of breath, sore throat, myalgias (muscle aches) as well as nasal congestion and runny nose.

If patients have that in addition to being exposed to known cases of COVID-19, then we give the patient a mask and we isolate that patient. So it's a work in progress. Let's first start with screening patients because that's the right thing to do for the rest of our patients, for the patient we're screening and for our healthcare provider.

Alicia Morgans: Absolutely and certainly for any patients listening, if you have a fever, you need to call into your clinic, your oncology office, your urology office before you arrive because these are things that you'll want your team to be aware of. They may say to you, hey, we need you to do this testing or that testing before you get here to just protect yourself and others. Or we may divert you to the Emergency Room or whatever facility to ensure that you are tested because fever seems to be a differentiating factor and it's important, as Dr. Choueiri said to recognize that not everybody with a fever and these types of symptoms actually has COVID-19.

People could have the flu, for example, which continues to infect people around the United States actually regularly at this time of year among other things. So it's really, really important to differentiate how this could be COVID-19 or something else and then sort of triage appropriately. And I know Dr. Choueiri, that you and your center are treating patients with bladder cancer, testicular cancer, urothelial cancer, kidney cancer. Are there settings in your particular practice, and I know that's mostly with kidney cancer, where you're making different decisions or at least considering COVID-19 as you're making treatment decisions for patients who are in front of you on a day to day basis.

Toni Choueiri: I think Alicia, this is an excellent question and we're starting by patients that are not getting systemic treatment first. What can we do for patients? So in prostate, bladder, kidney, testicular cancer, when you have, let's say, bloodwork and imaging and a guideline. But let's say we follow, let's say a treatment six months follow-up, and the patient is coming in three months, we have a discussion with the patient and that appointment can be pushed. More than me, in testicular cancer and kidney cancer that is resected or bladder cancer that we have a lot of guidelines that mention that say six to 12 months and here, if they're coming it happens in six to seven months, they could easily come in nine, 10 months. So we're changing the follow-up schedule.

Sometimes for patients especially out of state, they can get bloodwork. We have a lot of patients that can get bloodwork locally at PSA for prostate cancer and can fax it to us, especially if there is also another physician out of state that can handle changes in the scans, changes in the PSA. It is harder when folks are already on therapy, a planned therapy. So, for example, someone ongoing treatment with BEP, we met with our leaders here also in our group, like Dr. Sweeney with testicular cancer here. It's very hard to stop a curative intent therapy in the middle. So we are continuing to treat those patients, especially patients with corrective intent.

On the other hand, I'm going to give you a different part of the spectrum here. A patient of mine that was on immune checkpoint inhibitor every two to three weeks for the past three years who developed a near-complete response. That patient we started anyhow a discussion with them the past couple of scans to hold their therapy, to stop it and look at, because we know well with checkpoint inhibitors, some of these responses are durable and actually this patient called today to tell me that they're not coming in and that plan that we start talking about that was maturing in their mind actually now works very well. So they're going to stop their immune checkpoint inhibitor and come back in three to four months with imaging. Obviously we spoke on the phone and they don't have new symptoms.

So there is a spectrum when you deal with systemic therapy of decisions you can take to optimize precaution from COVID-19 because let's face it, you're coming to Boston, to a big town here, and you can do as much social distancing as you want, that's different than being at home.

Alicia Morgans: Absolutely and I love that you are really trying to optimize this sort of distance assessment or using the guidelines in a way, adhering to the guidelines in a way that allows you to adhere to the guidelines but also sort of push back things that are reasonably pushed back. But I'm not sure though when it comes to kidney cancer for example, in prostate cancer we can say when we look at it a given patient, if we have a number of treatment options available, there are some that we may say we're more likely to choose this treatment given the pandemic that's around us than this other treatment. For example, if we have to choose an AR directed therapy and that is sort of juxtaposed against a chemotherapy and they're equally effective in terms of disease control and we have the choice between the two of these, we may choose the AR directed therapy that does not cause immunosuppression in this setting just because of the pandemic.

Is there anything like that in kidney cancer or in any of the cancers that you treat that you think about? Or is that not really something that comes into play when you're talking to patients who are on active, who are making decisions about needing active systemic therapy? And you can even comment certainly in the adjuvant setting, I think there are some in kidney cancer, do we treat in the adjuvant setting? Do we not treat in the adjuvant setting? What are your thoughts there?

Toni Choueiri: So I think that's perfect, I mean I do treatment of prostate cancer still and the example you provided between AR target therapy versus let's say, docetaxel, work based on Dr. Sweeney in our group. You may choose the oral targeted therapy where the patient can stay at home and can be monitored with local labs. I get that very, very much. In kidney cancer or even in bladder cancer also, I think the question comes when you are starting immune... Luckily at least both in bladder cancer and in the kidney cancer in the adjuvant setting, immune checkpoint inhibitors are not standard. I'm not saying luckily, we don't know that because, with immune checkpoint inhibitors, you may have an immune-related adverse event that needs corticosteroid.

With single-agent checkpoint inhibitors, it's anywhere between six to 12% but we know very well when we use both in kidney cancer, such when we use the PD-1 inhibitor nivolumab and the CTLA-4 inhibitor ipilimumab, that chance of being on steroids that can decrease your immunity and blunt your immune system, is in the range of 30, 40% or even higher. So then that is a risk. Now, are corticosteroids a risk for COVID-19 susceptibilities specifically? What is the elegant study that shows us that? Well, none. There is no elegant study so and no studies at all.

We try to use common sense, like with other situations where we know that the use of corticosteroids can put you at risk for infections in general and why not even a viral infection. Especially with the chronic use of corticosteroids. So we try for example, with patients perhaps that may not need nivolumab and ipilimumab. Should we go by a TKI? Should we go by a TKI plus a PD-1 inhibitor or a TKI only? We take that into consideration but remember also that this is just happening now even I haven't even encountered a case maybe today only what I have to pick between both. But that's something we struggle even in real-time to pick up between I-O, I-O, and I-O/TKI.

Alicia Morgans: I completely agree and I love your reference to what is the elegant study that shows us that? What is the not elegant study that shows us that? We just don't have it yet and it's exciting to understand and to know that there are multiple people around the country, around the world who are trying to put together real-world evidence databases that will help us understand this. They will be what we have, we just don't have any of that now. What we do know is that patients who have cancer are at higher risk if they do get COVID-19 of having complications. Patients who are actively receiving chemotherapy are at higher risk of needing to go to the ICU or even dying from the disease.

But more than that, we don't know. And we actually only know that right now from patients who have cancer who are being treated in China. So we have so much to learn and so much that we hope to understand, to avoid and to do right when we are treating these patients. And I sincerely appreciate your expertise as we try to work through this. Do you have any closing thoughts for those who are trying to take care of their patients with GU malignancies as we work in the era of COVID-19?

Toni Choueiri: Yeah, no. Thank you, Alicia. I think very important communication at every level. I know you and I use social media heavily. We use those judicious social media here to spread real information in real-time because the situation is very, very fluid just by the hour. We also adhere, both of us, you work at an impressive institution, Northwestern. We work here also at Dana-Farber. We have our own guidelines so I rely a lot on our leadership and the guidelines, you know that Dana-Farber, issues for us clinicians and we have people, administrators and physicians working around the clock, a COVID-19 task force to stay up-to-date with everything and we adjust. Luckily here we do have, despite having numbers of cases in Massachusetts, we follow these cases closely, we follow what is the death rate and others, who has what and adjust very, very fast and in real-time. All hands are on deck.

Alicia Morgans: Great. Well, I certainly wish you the best to you, to everyone who works with you and to all the patients that you care for and to certainly the patients around the United States and around the world who are trying to deal with the cancer diagnosis while also trying to deal with the stress of COVID-19 and I sincerely appreciate your time as we move through this difficult situation. Thank you so much.

Toni Choueiri: Thank you. And thank you, UroToday, for everything you do too for the urological and the GU medical oncology community.

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