Managing GU Cancer Care during the Disruption of the COVID-19 Pandemic - Tomasz Beer
March 24, 2020
Tomasz Beer joins Alicia Morgans from Portland, Oregon, to share how his clinic is shifting priorities to prepare for the COVID-19 global pandemic. Since cancer patients are among some of the highest at risk of contracting COVID-19, Dr. Beer outlines the clinical differences he is seeing in his practice, and how his team is implementing virtual visits (telemedicine) to maintain social distancing in order to keep healthcare workers safe.
Tomasz M. Beer, MD, FACP, Professor of Medicine, Division of Hematology/Medical Oncology, School of Medicine. Grover C. Bagby Chair of Prostate Cancer Research
OHSU Knight Cancer Institute Deputy Director, OHSU Knight Cancer Institute, School of Medicine. Chief Medical Officer, CEDAR, OHSU Knight Cancer Institute, School of Medicine. Cancer Biology Graduate Program, School of Medicine
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, this is Alicia Morgans, Associate Professor of Medicine and GU medical oncologist at Northwestern University. I am so grateful to have here with me today Doctor Tom Beer, who is one of the leaders in the Division of Hematology/Oncology at OHSU, where he's also the Deputy Director of the Knight Cancer Institute. So grateful to have you here with me today, Doctor Beer.
Tomasz Beer: Great to be here with you, Alicia. Thank you for having me on.
Alicia Morgans: Wonderful. So I just wanted to talk with you a little bit about how you and the folks at OHSU are experiencing the COVID-19 pandemic, what you're doing to address the challenges that you see to both keep clinicians safe and also to, of course, ensure optimal patient care. How are things in Oregon?
Tomasz Beer: Well, we're fortunate here in Oregon a little bit to be, I think a couple of weeks behind our neighbors up to the north in Seattle. So we've had the opportunity to prepare for what we expect to be an onslaught of patients suffering from the COVID-19 viral infection. The last couple of weeks have really been all about getting ready and implementing social distancing that everyone has recommended. We focused on dramatic changes in our laboratory and clinical research efforts and have moved aggressively to move as much of our outpatient care as possible to remote visits.
Alicia Morgans: So let's think about each of those things one at a time because I know you and I have actually had some conversations where we participated in some similar research programs and your institution's take on clinical research was different than my institution and as many of us are struggling with how to maintain, or perhaps curtail for a time being our clinical research programs. What are you doing in Oregon to try to address this particular issue?
Tomasz Beer: Well, I think the range of responses has varied across the country. We've talked to our colleagues at many institutions and we've seen everything from a complete halt to clinical trial accruals to much more modest measures. I think all of us are deploying the kinds of solutions that work for our community and our particular challenges.
Here in Oregon, we have thought about clinical research in terms of interventions that directly impact the health of participants as something that is quite different from other types of interventions like screening or monitoring of patients or studies that may focus on survivorship but not directly on immediate human health and we have supported the continuation of essential treatment clinical trials while we have put on hold largely the entire portfolio of non-treatment studies in cancer.
Even within those treatment trials, we have really focused on continuing those study processes that directly support the health of the individual participants. So assessments of tumor status, response to treatment, assessment of patient safety, but things that don't directly care of that patient are generally on hold now.
So from kinetic studies, correlative assessments, additional evaluations, while important in a big picture, don't impact on that particular patient's health are currently on hold to minimize the number of human interactions and support the goals of social distancing.
Alicia Morgans: I think our institution is doing some of the very same things where we're really continuing those therapeutic trials and not necessarily all therapeutic trials. We've identified some that... The leadership has identified as some for populations that may be at highest risk and they don't have other options, but really our survivorship and other non-interventional trials are minimized which it sounds like you're doing too.
As you also are supporting your clinicians in their clinical care, how are you, like you said, you're working to really make sure that as many of these visits are remote as possible. How are you doing that in a scalable and reasonable way? Do you have any advice for other groups that are in the early days of trying to make that happen?
Tomasz Beer: I think, first of all, we're driven by the recognition based on the data coming out of China that cancer patients and even cancer survivors are really in the highest risk groups for COVID-19 complication and mortality. What we're seeing and the numbers are small on the data, of course, are preliminary, is that death rates in cancer patients infected with COVID are at times higher than even the 80 and above age groups that we typically think about as at the highest risk.
So we're really driven by a concern about our patients' safety and recognize that every interaction, the waiting room, the check-in desk, the interaction with the medical assistant, the physician, other patients in the hall, those are all small violations of the goals of social distancing. So based on that, we're really trying to limit those maximally.
Secondly, we're focused on their health and wellbeing of our healthcare workforce and the same principles apply. The fewer face-to-face direct human-to-human interactions, the less the chance of coming down with an infection.
So we've moved fairly aggressively to move as much of the care as we can to phone and video. In the first week or so, we really just switched to phone visits for everybody that we could reach that would be comfortable with that, with no billing or anything of that nature. We just basically arranged for lab work to be done, if necessary, locally and called our patients and talk through how they're doing. A little bit more practical in a prostate cancer practice where laboratory results and a phone interview may give you all the information that you need. It may not be workable for some other cancer type but in prostate cancer, we've quickly found that a substantial majority of our visits really don't require a physical exam and with a careful history, maybe a little more extensive history than you would ordinarily collect to make up for the lack of a physical exam. We think we can take good care of most of our patients.
The institution is pretty quickly developing more formalized means of delivering care remotely through scheduled telephone visits that do enable some billing and virtual visits via telemedicine, which is being rapidly liberalized and made available initially in primary care and we hope in oncology by next week.
Alicia Morgans: Great. So, what advice would you have with where things currently stand for you, for those who are a few weeks or maybe even just a few days behind your experience in Oregon and of course I asked this, recognizing that in a week or two things may be even very different for you where you are. But for those people who are not in the thick of things, even as much as you, what advice would you have or recommendations or guidance?
Tomasz Beer: Well, we're still learning. We've really only done what I've described for about a week and a half and it's changing every day. But when I think about an average clinic day for me, for example, let's say we see 25 patients, most of them bring one or two family members in. When you add it all up it's probably 75 to a hundred unique human interactions in a day and that's just not consistent with trying to maintain social distancing and preventing the spread of the virus.
So, I guess on the basis of our experience, my advice would be as quickly as possible, take a look at your patient panel starting with the longterm follow-ups, the patients for prostate cancer with a slowly rising PSA or even in remission on an annual visit or on routine hormone therapy, doing well in response, those patients really don't need to be seen face-to-face. They can be taken care of by phone.
Number two, we've rapidly switched nearly all of our patients as they come into six-month hormonal therapies. We don't know what the world's going to be like in three months but recognizing that every visit to a healthcare center may be a risk for elderly cancer survivors, we want it to as much as possible reduce the need for an injection and in three or four months.
Then, the next step that we're taking is to try to more broadly implement video-based virtual visits, which we think would enable us to expand remote care to nearly all of our patients.
Alicia Morgans: Well that's very helpful. You're the first I've heard who's switching people to six-month injections. I'm in clinic tomorrow and I think I'll be doing the same. Of course, for all of us in clinical practice, this includes telling our pharmacy that we're going to need to order some more of these and this can work for urology practices and medical oncology practices, as long as we are cognizant of ensuring that we are following up with our patients if they are on other oral agents, if they need to hear from us and that telehealth is a great way to do that.
So thank you for that very real, very practical advice and I wish you and your team the best as you continue to move forward. We will have to circle back with you and hear how you're doing in a few weeks.
Tomasz Beer: It's great talking with you, Alicia, and best of luck in your practice and all around the country. These are challenging times but I think we'll learn a lot from this and come out stronger on the other end.