How COVID-19 Is Impacting Cancer Care in NYC - William Oh

William Oh, a GU medical oncologist practicing at Mount Sinai in New York City, joins Alicia Morgans to discuss the impact of the COVID-19 pandemic. With testing being ramped up at Mt. Sinai and the disease evolving at rapid speed, Dr. Oh discusses testing criteria for COVID-19 in cancer patients, how they approach safely discharging cancer patients from the inpatient units, and what role telehealth is playing at this critical time.

Biographies:

William Oh, MD Chief of Division of Hematology and Medical Oncology, Deputy Director of The Tisch Cancer Institute, Professor of Medicine and Urology at Icahn School of Medicine at Mount Sinai in New York

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. This is Alicia Morgans, GU medical oncologist, Associate Professor of Medicine at Northwestern University. I am so honored to have here with me today Dr. William Oh, who is a Professor of Medicine and a leader of the Hematology/Oncology Division at Mount Sinai University in New York. Thank you so much for being here with us today, Dr. Oh.

William Oh: Thank you, Alicia.

Alicia Morgans: So William, we have asked members of the GU oncology community around the world to lend their perspectives, their insights, their guidance, their messages for how we can do better in light of the COVID-19 pandemic that we're all experiencing and that we're trying to work within as we also continue to care for our patients with GU malignancies.

I know that New York as of today, the 21st of March, 2020, is being hit rather hard by this pandemic and I would be so appreciative if you could share some of your experiences and your thoughts on what you're going through at Mount Sinai.

William Oh: Sure. It's really my pleasure to speak with you and to try to give some people out there a sense of what's happening in New York. It has become, as you know, a key area with very rapid growth. I think this morning it was over 6,000 cases, and I think New York has like 40 to 50% of all the cases in the United States.

I think a big reason that there's been such rapid growth over this past week has actually been the testing has been scaled up very, very fast. I think this is really a very important key for us as healthcare providers because we're really flying blind in the absence of testing. We didn't know if our cancer patients with a fever or a cough had regular pneumonia or whether it was related to their immunotherapy.

We really didn't understand what was happening until we were able to get widespread testing. Not only do the state labs and obviously the CDC offer the tests, but now in New York, all of the private labs including the large commercial labs, but Mount Sinai itself is doing the rapid turnaround COVID-19 or coronavirus testing.

So this has really expanded our ability to test every single patient under monitoring and every patient under investigation, at least these two categories when patients are admitted to the hospital, symptoms that put them into higher-risk categories.

So it's really allowed us to understand who we should treat differently to kind of preserve the PPE, which as you know is a huge issue, including at Mount Sinai. I think that for the most part, you know, everyone is dealing with the situation, given the increasing restrictions on travel, increasing personal sacrifices that people are making in terms of their families, really to protect our patients, but also to protect ourselves.

Alicia Morgans: So I'm glad to hear that you and your system are able to do this testing, that's it's ramped up so broadly and is now available in New York. It's not necessarily as available I don't think as we talk to folks around the country, but that's where we all hope to be.

As we move in that direction, what would you say are the criteria that you're currently using to test patients? So how are you choosing those patients? Because I have heard some who have had access to the test, not necessarily in the US, but in other parts of the world who have said we really are trying to test everybody, because unless we test everybody and have a bunch of negatives we're actually not sure that we're capturing that whole population at risk and we could be missing many patients or many people who could be passing on the virus, whereas others, particularly because of situations where there's limited access to testing, said we really have to prioritize which patients we're going to test and use those patients... Testing those patients in whom we think we have the highest pre-test probability of having a positive.

So as you are finding the testing is more available in New York, who are you testing? I'd love to hear your thoughts on both an inpatient and outpatient perspective for that.

William Oh: Well obviously this is all happening very quickly and we're getting from the Mount Sinai leadership daily updates, and really honestly changes. When the testing wasn't available it didn't matter who we were seeing. We couldn't really test them, and that was literally a week ago.

I think that the usual priorities are evolving, and because we have more mobility, anyone with a cough and exposure to a known COVID positive patient, particularly if they're in a vulnerable situation, if they're admitted to the hospital, we're able I think now just in the past few days at Mount Sinai to really test all of these patients.

We can actually... We just expanded an ambulatory testing, meaning that in our cancer center we can actually swab our patients for the COVID-19 virus. Up until just a few days ago, everybody was sent to the emergency department to be tested.

As you know, there are these drive-up testing sites. I think there are three or four in the New York metropolitan area. We do not have one ourselves yet. The bottom line is that anyone with any suspicion, particularly really related to the severity of their illness and the likelihood that they're in a position that they may actually infect others, I think in that situation we would actually send for testing.

Now in my own practice, which is the main way that I can assess this, a lot of our patients may have, for example, a week ago if a patient called me with a cough and a fever but was otherwise feeling okay we would just simply tell them to self-isolate, just because we could not get access to the testing. Now we can have those patients either come into our ambulatory center or into the emergency department and get tested.

This is really why I think we've had such a rapid rise in New York in terms of identifying these cases. There may be other reasons that are unique to New York. New York City is a very crowded metropolitan area and there may be much more asymptomatic spread than might be true in other parts of the country. I suspect that there probably are a lot of undetected COVID-19 and relatively asymptomatic people, and this is why you're seeing this dramatic self-isolation that's occurring, these shelter in place type of orders.

In the inpatient service, I think Mount Sinai now has several hundred patients who are positive across the health system. I rounded on one this morning. She's a breast cancer patient, because I'm on the solid tumor service, and is actually... Has metastatic breast cancer, is actually recovering quite nicely from the virus. She's had it for several days, was admitted a few days ago, and now the whole issue with her again is that Mount Sinai created a separate unit, four separate units, where COVID-19 patients are isolated.

Again, the biggest challenge is getting PPE and trying to preserve PPE, but this particular patient seems to be improving. What we don't know, for example, is what the discharge planning is for somebody like this. When she can be safe to go home? Should we be testing her to make sure that she's negative on one or two subsequent viral tests? Those are questions I actually do not know the answer to yet, but I think it's just everything is moving so quickly that once she can go home, isolate until she's asymptomatic for a certain number of days, that ID will tell us that we will actually discharge her from the hospital so that we have that bed available.

Alicia Morgans: Wonderful. And like you said, this is evolving so rapidly. I'm glad to hear your patient with COVID-19 is getting better, and we will be sure to come back to you in a couple of weeks as we're recording followups with everyone, to have some followup with you regarding what are your plans in terms of discharge.

I think as a field we're going to hopefully have some more guidance on that, hopefully within two weeks, hopefully for your patient within the next week or so so that she can get home and be well and continue to recover.

As you continue with your day-to-day, given that you're Chief of the Division, I'm sure you have a lot of decisions to make, and again, as you said, lots of urgent meetings to really help keep not just our patients safe, but to keep our clinicians safe, to keep our support staff safe.

Are there ways that you are engaging with telehealth or remote visits that are working for you in your practice, or is that something that perhaps you're not necessarily doing at this time? The reason I ask is because folks across the country and around the world are doing various permutations of this and having various successes and learning from it that really can help to guide those of us who are still figuring it out, as we all are, I guess.

But are there ways that you're using telehealth for these visits, or maybe just deferring visits, that are working for you as you're trying to keep your staff and clinicians and others safe?

William Oh: We're really doing both, Alicia. We've actually cleared our schedules for all elective followups. You'd be surprised in a GU practice how many patients don't actually have to come in and see you. A lot can be done with local labs if they have to have labs done, and in fact many of my prostate cancer patients, and I have a primarily prostate cancer practice, do not need active visits.

What we've been doing is trying to convert them all to telehealth visits. As many people know, Medicare has created an urgent new allowance for defining a telehealth visit as anything similar to using an iPhone or an android. We actually are trying to do it more formally and we've been rolling out telehealth at Mount Sinai and we're just getting everyone up to speed.

So on my clinic on Monday morning we've canceled about half of the visits, and people who need calls to discuss a CAT scan or a bone scan, I may call them. But what we're trying to do is create formal telehealth scheduled visits within Epic, we use Epic.

So it is a learning process, but I think the goal is to really minimize exposure of the patients for the need to come into Mount Sinai, and vice versa, for our patients who may be carrying the virus to come in and expose staff and other patients, so we are taking a very aggressive tact towards this.

All of our conferences are obviously canceled. All of our meetings are done through videoconferencing. We have been having weekly town halls for the cancer center. This is in addition to the medical school that's been having regular town halls.

We are all obviously trying to make sure that we stay as well-informed as possible, but because everything changes so quickly it really is obviously a challenge, and dealing with anxiety I think is one of the biggest challenges.

I will say Mount Sinai has done a very good job of communicating. They've created a website that actually is publicly available. It's no longer an internet, so if people want to actually look at the resources available on the Mount Sinai website, they've done a really excellent job of keeping it updated because so much information comes from your department, the cancer center, the medical school, the hospital, and we're a seven-hospital system, so it's very, very difficult sometimes to get the straight story.

Then within our division and within the cancer center, we have made a lot of our own decisions that really piggyback on the issues that let's say the Department of Medicine or that the institution itself makes. For example, we're thinking about our cancer patients may be in a similar way to other immunocompromised patients, but I think we want to go a step further and really consider what urgency and needs of our cancer patients are.

But that said, you don't want to send too many messages in an emergency like this. People get really confused when one person says one thing and another person says another. So we're trying very hard to use our institutional guidance, but also try to interpret it in a way for cancer-specific patients and our faculty.

Alicia Morgans: Well I really look forward to hearing how you continue to find successes in all of this and care for your patients and come up with new ways for all of us to improve our practices to keep patients well, and so appreciate your time. I would love to hear if you have a final message for the listeners as they go through this on a day-to-day basis.

William Oh: Well, of course, we're all scared and concerned. There's nothing like this that any of us have ever really lived through. But I think what we can do is support each other, and it's through informational opportunities like this, Alicia, that you are doing, and really to support each other as much as possible.

Doctors are information hounds. The more we learn from each other I think the more comfort we have in the fact that we will ultimately get through this. I want to wish everyone the best, and stay safe out there.

Alicia Morgans: Thank you so much. Stay safe yourself too and keep up the good work. Thank you for your time today.

William Oh: Thank you.