COVID-19 and Cancer Care at St. Barts Cancer Institute in London UK - Thomas Powles

March 21, 2020

Recorded Date: March 19, 2020

Thomas Powles from Barts Cancer Institute in London joins Alicia Morgans to discuss how the GU medical oncology and urologic oncology communities are preparing for and caring for people with genitourinary malignancies in light of the global COVID-19 pandemic. Dr. Powles provides a European perspective on the state of the virus today.   As the cancer center director Dr. Powles shares how he and his colleagues have been rearranging services, changing protocols, adjusting therapies, retraining some of their workforces, and adapting to the changing environment. In closing, they reflect on the triage differences that are being seen around the world.


Thomas Powles, MBBS, MRCP, MD, Professor of Genitourinary Oncology, Lead for Solid Tumour Research at Barts Cancer Institute, Director of Barts Cancer Institute, London, United Kingdom

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, so happy to have here with me today Dr. Tom Powles who is a Professor of GU Oncology, the Director of the Barts Cancer Centre in London, England, where he practices and cares for patients who have GU malignancies. This is Dr. Tom Powles. Thank you so much for joining me today, Tom.

Thomas Powles: Thank you for inviting me.

Alicia Morgans: Of course. I'm so pleased to have you here just to talk about what you are experiencing and what you see to come, and how we as a GU medical oncology and urologic oncology community can sort of move forward caring for people with GU malignancies in light of the COVID-19 pandemic. I'd love to hear your thoughts, Dr. Powles.

Thomas Powles: Well, I think the first thing to say is that we're living in really, I think, for certainly the current living group of people, I think you have to go back a long way to find a similar health challenge. I think the difficulty we're having, in my opinion, is it's happening so quickly, and that there's a huge amount of uncertainty about what the future holds. The experience from Italy, northern Italy, and Spain is quite alarming. I'm in regular communication with colleagues from Spain, Italy, France, and the US, of course. The impression I get is that the hope initially was that this was sn isolated problem that would occur in one or two small areas and wouldn't spread, has not turned out to be the case. What we see, I think quite clearly is that the steepness of the incidence curve appeared or has appeared until recently to be exponential.

It also appears that that curve, irrespective the quality of your health care system, northern Italy has a fantastic healthcare system, enviable of around the world, can become overwhelmed very quickly. The European perspective seems to be a domino type effect where the process moves from country to country depending on where you started in that curve. London is in the UK, is slightly behind Italy, Spain, probably in the same sort of ... maybe we're about three or four days behind France. If you look at our cases and our mortality. The area which I can talk about is from a cancer center perspective. I don't work in accident and emergency, but I'm Director of Barts Cancer Centre, and we've been rearranging our healthcare services for probably two and a half weeks now with quite detailed planning, which I participated in. But a number of other people have had much more day-to-day. You know, a huge amount of work has taken place.

What we are doing is we are, In the UK, we have a large number of infected individuals and that includes some cancer patients and that includes obviously some cancer patients on treatment, as you would expect. What we have, at the moment, I think is a hospital in which we are separating into areas which are, COVID-free and other areas that have COVID-infected areas. We have obviously patients who require ventilation and respiratory support as you would expect. As it currently stands, we're coping relatively well. The question from our perspective is whether we've hit that steepness of the curve yet, whether actually the big challenge is in two weeks' time.

I think at the moment there is a feeling of relative, there's a huge amount of preparation. We've essentially made the hospital an area in which you were only in if you've got a health care problem. We've cut back maybe 50 or 60% of our systemic therapies, we've done that. That's been protocol-driven. So we've changed our protocols. Things like adjuvant therapies, palliative therapies, high-risk therapies, immunosuppressive therapies, therapies that don't need to start immediately. We've reviewed those as a group and put many of those on hold. We've freed up a number of cancer beds, we're retraining some of our workforce. We're preparing for what we hope won't happen, but what we think will, which is a similar situation, but we hope we're going to be better prepared. Not because we have better health care systems, but because we've had more time than some of our European partners.

Alicia Morgans: Absolutely. I think that's what we in the United States are hoping that the social distancing, the sort of staggering clinics to really include only those patients who are in active treatment will, if not prevent patients from being infected because we hope but cannot guarantee that. But to sort of stagger the time over which they end up hitting the healthcare system and needing to be admitted to the hospital and potentially to our ICUs, and it's encouraging to hear that that's what's happening for you in London as well. Have you seen any patients with COVID-19 yet? Is it something that you've dealt with in your clinical practice? Maybe not necessarily on the front line, if you're as an outpatient doctor, presumably really who's giving treatment for patients with bladder cancer or other cancers, usually in an outpatient setting. But have any of your patients contracted the COVID-19 virus and how are you dealing with it, if so?

Thomas Powles: So I'm the Director of the Cancer Centre and inevitably with a population of 2.5 million we're going to have cancer patients and other patients who test positive. There is, as, in the US, we don't have a perfect testing system yet. We will have a much better testing system very soon. I think WHO advice on test test test is probably right and I think we need to develop an antibody test as well, particularly for staff to work out who's been infected previously because we're going to need to get the staff back to work. I think one of the three things we're working really hard on at the moment is to make sure, number one, the hospital's safe and the patient's protected. Number two is the workforce is being protected as much as we can and the workforce is functional as it can be. And number three is we're communicating from a Cancer Centre perspective on a regular basis with our partners and our staff to make sure people are fully informed and we're as transparent as we can be.

So, yes, we do have and have had infected patients. The UK is a little bit ahead of the US in terms of, I think, the incidence of the current disease, or certainly from a testing perspective, and while I realize there have been more deaths in the US, you've got a population of 350 million, we have 50 million. So I think our per head death is probably not that different from the two countries. So I think there are many parallels. Clearly, London because of its international links has the highest incidence in the UK. So we probably are in parallel to Seattle and New York. So yes, we do have cases as you would expect.

The key to that, as is happening in the US, it has been around really tight protocols on how we deal with positive patients. Do they need to be in the hospital? Do they have a cancer problem or an infection problem? Do they have symptoms? And what is the risk to our cancer patients? So the way we're dealing with them initially is, as with the rest of the population, one of the challenges around the future is to work out is, it's not clear, I think these patients are at increased risk, number one. But number two is, we're in an era of limited resource, how do we make sure that our cancer patients get the best treatment that we can give them? We are currently not in that position that I think is the case in Spain and in Italy, where there is not enough resources to go around. But one of our hopes is we don't get there.

Alicia Morgans: Absolutely. I completely agree. You raised a really interesting point, one that we've not actually talked to folks about on UroToday about, but I'd love to kind of dig into this a little bit. So as we move past the acute issue, and actually even while we're in the midst of it, some of our healthcare workers may be exposed, may have a clear infection or may have an undiagnosed infection, and may recover either way and be on the other side of it and an antibody test that can demonstrate that they have IgG titers against the COVID-19 virus, I think it's going to be a really important part of us saying, "Okay, you're immune to this or you've been exposed to this. We can safely hope that you can come back into the workforce."

Now, of course, we don't know if patients who've had exposure will necessarily be then immune and there were cases, I think at least one in Asia, where someone had been exposed and then was sort of reinfected. So we don't know necessarily, we're still learning, but this test to identify patients who have been exposed and then who might be able to have some immunity and come back is going to be really important for us to repopulate our health care workforce. It sounds like that's something you're thinking of.

Thomas Powles: Yeah, so the infection professionals in the UK working for NHS England, their current position is the likelihood is we will build up some immunity to this. If you've been previously exposed, that may or may not be perfect, but your risk will decrease. The risk associated with health care professionals, most of whom are in what I would describe, low-risk group, looking at the data coming out of China initially, suggest once you've been infected, if the risk of reinfection is low and I think that's going to be the case, then very positively we can get a big workforce back into the hospitals and that seems to be a short term problem. One of the issues with current tests is if we're not testing healthcare workers when they're potentially infected, then they get a new infection two weeks time, we can't guarantee that they didn't have previously a different infection, which means the same group of people are going to be out of work and we need to, during this very difficult time is have as many health care professionals working as possible, and we probably need to retrain healthcare professionals.

For example, oncology is becoming a less useful specialty than it was because it's not the chronic disease in the, well, vast majority. Yes, there's emergency tests, cancer, and lymphoma type treatments, and of course, some patients need emergency chemotherapy and other treatments. But a lot of what we do is chronic around disease control, and therefore, I can see a number of our groups being named in different areas in the short term. I think there's a lot of concern, and I think there's a lot of ... I have a huge concern about the steepness of the curve and the healthcare systems being overwhelmed because I think if clearly [inaudible], then the mortality is going to increase and then there will always be a debate about who gets access to those ventilators, and we've had those discussions and they are clearly quite negative and they are short term discussions. The medium-term discussion is around getting the workforce back into place, getting more ventilators. So we are hoping to quadruple the number of ventilators in our hospital, we've already started that process.

Number three is we're talking and we learning about new treatments. I was on the phone with the team from Seattle earlier today. Large numbers of trials with drugs. We're talking about tocilizumab but I know there are a number of other agents that are being investigated. Of course, we are going to do better fighting this virus, which, it's very unlike humans to sit on our hands and watch things take us over and the fightback has started, and I see much of that as being quite positive. Don't get me wrong, this is going be very difficult and it's going to be very disruptive and as many people have said, people are already dying and more people will die.

But at the same time, this I don't think will necessarily be the be-all and end-all, I hope because I think we'll, as a group fight back, I think we will get better at treating patients who are infected. I think we'll get better at identifying people who have been infected. I think we obviously are going to develop a vaccine I hope in the not too distant future. And those patients who require ventilatory support, I think we can get better at treating those as well. So inevitably, I think there is some progress, although I think the next two or three weeks are going to be extremely challenging in London.

Alicia Morgans: I love what you're saying, I love your vision for hope and I love your idea that the fightback has started and I think if any community is ready to fight, it is the oncology community where we fight cancer all the time, and we fight to maintain quality of life. We fight to maintain our patients' lives just as they are on a day-to-day basis in any way that we can. I sincerely wish you luck in the UK, in London, as you continue this fight and I'd love to hear if you have just a final word of advice for those in the US, for those around the world who are taking this on in our GU oncology community. Any advice that you have?

Thomas Powles: Well I think there are two or three things and I won't take up too much of your valuable time. I think the first thing is that there is still feeling in some communities that this may not hit us. The reality is I don't think that's correct. I don't think this will be contained and I think it will arrive. So, therefore, I think we need to prepare for that. So my advice is, of course, hope for the best, but I would prepare in the short term the worst. The reason why that's the case is because I think if we prepare like the Seattle team and the Paris team earlier today, both of whom are making huge preparations and are doing great work, and like if we learn from each other, we will serve our patients well. That's the first thing I'd say.

The second thing I'd say is, I think you need to think very carefully about the treatments that we're giving right now. So if you're going to give chemotherapy today, I don't think you can predict [inaudible] in five or six weeks' time, or three weeks time when the patient may get side effects. So think very carefully about starting treatment. Don't think about what it looks like today. Think about what it looks like in two weeks time. The key to this is, in fact, I heard an American politician, who I won't name, say this earlier today, and I think he was right about it. If you're thinking about dealing with today's problem, you're not thinking about what the problem really is because, by the time you've put your plans in place, this will have escalated. So you need to think about what it's going to look like in two weeks' time. Until you've got control of that curve, you have to make the assumption the curve is going up. So giving standard type chemotherapies, as it currently stands because your current healthcare system is working, don't think that. Think what might it look like in two weeks' time before you push the patient into that swimming pool, not knowing how long they're going to be under the water for. That's the second important thing I'd say.

The third important thing I'd say is I do think that we are beginning to come together as a group and start solving the problems associated with the virus. I actually do think there will be light at the end of the tunnel, although the next two or three weeks will be difficult.

Alicia Morgans: So thinking about working together, learning from each other, making sure that we make smart treatment decisions that anticipate the way things may be in the future, even if they seem stable today, and making choices that protect our patients, considering the worst while hoping for the best is absolutely critical. Thank you so much for your ultimate message of hope. We will continue, I hope, to hear updates from you as we deal with COVID-19 in our cancer patients over time. I sincerely appreciate your time and wish the best for you and all of your patients and everyone you work with. Thank you so much for your time, Dr. Powles.

Thomas Powles: You too, Alicia. Good luck out there.