The COVID-19 Pandemic Impacting Clinical Urology in Los Angeles - Stephen Freedland
April 12, 2020
Stephen Freedland speaks to Alicia Morgans about the changes COVID-19 has brought to his clinical practice and research in Los Angeles, California. Dr. Freedland reflects on his clinical practice, noting that the halting of elective procedures has canceled all Benign Prostatic Hyperplasia procedures, while prostate cancer patients are being assessed on a case-by-case basis as most in-patient care has become more phone-based. Freedland also speaks from his perspective as the editor in chief of PCAN — mentioning that the journal has received more submissions than usual, likely due to the fact that physician-scientists are shifting into working from home and thus focusing on writing. he states that at the same time, clinical trials and other studies are being put on hold. Finally, Dr. Freedland touches on the challenges posed by this unprecedented time and some ways to relieve stress.
Stephen J. Freedland, MD, Director, Center for Integrated Research in Cancer and Lifestyle, Co-Director, Cancer Genetics, and Prevention Program, Associate Director, Faculty Development Samuel Oschin Comprehensive Cancer Institute, Professor of Surgery, Cedars-Sinai, Los Angeles, California
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 and GU Medical Oncologist at Northwestern University. I am so delighted to have here with me today, a friend and colleague, Stephen Freedland, who is Warschaw Robertson Law Families Chair in Prostate Cancer and Director of the Center for Integrated Research and Cancer and Lifestyle and the Co-director of the Cancer Genetics and Prevention Program. Many titles for Dr. Freedland, but also a phenomenal clinician, a wonderful researcher at Cedars-Sinai. Thank you so much for being here with us, Dr. Freedland.
Stephen Freedland: Well it's great to be here. Thank you so much, Alicia.
Alicia Morgans: Thank you. So, we are talking to people around the country, around the world actually about how they are being impacted by COVID-19 and I'd love to hear your thoughts on how this is impacting you, and your clinical practice, and your day-to-day.
Stephen Freedland: Yeah, so in terms of the clinical practice, so Cedars has basically canceled all elective surgeries and the definition of elective is a little loose and unclear, and really up to a lot of interpretations. A lot of my clinical practice is actually BPH related, even though the majority of my research is prostate cancer, so BPH is clearly a general elective. So all my BPH surgeries have been canceled. In terms of prostate cancer, it's really on a case-by-case basis, discussing with the patient, but there's no one size fits all. It's a tough discussion to have with the patient and they come in with an elevated PSA. Should I have a biopsy now or should I wait until all of this is over? And I think obviously we don't know when this will be over, right?
I mean if we knew, for example, in two months from now everything was going to be 100% fine, we can go back to our old life, I think a lot of people say, "That's fine, I'll just put a pause on things for two months. Fortunately, it's prostate versus other cancers. Two months doesn't make a huge difference in general. I can wait for my elevated PSA, or for my biopsy, or my radical prostatectomy." But we don't know it's going to be two months. It could be three, it could be four, it could, you see projections of 18 months. I mean hopefully not, but none of us really know. So I think it's really sitting down with the patients so to speak, sitting down by phone, and talking with them, and figuring out what's the right decision.
I mean I can tell you right now, my clinics, which normally are relatively busy, are mostly phone-based. Very few patients actually physically coming into the office and I think actively we're trying to limit the number of patients walking in and out of the doors. It creates a risk for them and prostate disease affects older men. I mean often have co-morbidities, that's the exact group that's at highest risk of COVID, men, older, with co-morbidities. So we're really trying to do them a service and us a service and really get ahead of the curve and flatten the curve.
Alicia Morgans: I think that sounds so much like what we're experiencing throughout the rest of the country for sure. And I know, I appreciate that, and I know that a lot of what you do besides clinical care is also related to research. You're actually the editor I think of PCAN, the Prostate Cancer and Prostatic Diseases, the Editor in Chief. Can you tell us a little bit about how research is being affected in COVID-19, and maybe we're not feeling that effect yet. Maybe you're still getting a lot of articles that are being completed as right before this started, but maybe we're starting to feel a decrease in productivity? What are your thoughts in terms of that?
Stephen Freedland: So, it's a great question and I think in terms of are we able to maintain productivity, I think it depends on who you ask. So if you're asking the faculty level, the PI, the clinician who, or even the non-clinician PI who's used to running the laboratory and doing lots of experiments and supervising that that can't be done because people are told to stay home, or someone, a clinician is not doing surgery because surgeries are canceled and patients don't want to come into clinic, they actually have increased free time. So I'm actually seeing anything from the journal perspective, slightly uptick in terms of the number of submissions because I think faculty level people have projects that were basically done and just needed someone to write that paper, are actually getting done.
I think in terms of new patient accrual to clinical trials, to observational studies where it's dependent on you're still accruing the data, or you're doing the mouse study, or the in vitro study, those have by and large been put on hold with some exceptions. I mean if you're on a therapeutic trial where we're testing out chemo A versus chemo B, you think that's going to be life-saving for this patient, those trials are still ongoing. But if it's, hey, we just want you to fill out some questionnaires so we can learn a little bit about the disease, we've put those on hold. So I think there's decreased data generation, but at the same time, it's allowed some of the faculty time to analyze and write up the data that they already had in hand. So I think the short answer is people are making the best of the situation. It's obviously a very tough situation for lots of people and everyone's doing the best they can to keep productivity and their lives together.
Alicia Morgans: I think that's a great way to put it. And I'm encouraged to hear that things that have been sitting on desks are moving through and that's great. One of the things though that you focused on as an investigator, as a clinician, are things like lifestyle and things like staying healthy through tragedy or through stress. So are there things that you advise your patients or things that you could advise certainly the listeners, the clinicians, as we all deal with the stress of COVID-19?
Stephen Freedland: No, it's an excellent point and I think it's a very stressful time. And when stressed, we as humans, and there's actually brain research on this and there's a very interesting book "Thinking, Fast and Slow" I think was the title that talks about this. But when we're stressed we often don't make good healthy choices. So, there's a reason we talk about comfort food. People are feeling stressed, you want comfort food, which is generally not synonymous with healthy foods. The reason it's called comfort food and not healthy food. So I think to maintain a positive attitude, try and continue to eat healthily, get the exercise, there's a story online where a guy on his balcony ended up walking 26.3 miles on his balcony, which is the length of a marathon. He basically ran a marathon on his balcony without never leaving his apartment.
So it pushes us to new challenges for sure. I mean, the gyms aren't open. We can't walk to work or bike, or even walk around campus because we're sitting in our rooms, in our house, on telephone calls, or on the computer all day. But there are ways to try and think about standing desks, take a break, walk around, try and maintain that physical activity because that's so important. And it's actually some suggestion. I mean, I'm certainly not a COVID expert by any stretch. There are some suggestions I've heard that people who are healthier and maintain good sleep habits, I think that's very important, eat right and exercising may be at lower risk for COVID. I mean, we certainly know they're at lower risk for general infections and general co-morbidities. So it makes sense. But I think that's so important, especially in this time of unprecedented stress, and anxiety, and upheaval to our world at the moment.
Alicia Morgans: So great advice and thank you. We have not had anyone really comment on how to deal with these things quite in that way and I really appreciate that. And as you're giving great advice maybe we'll ask for some more. Do you have any sort of just general messages to clinicians, to researchers as they're trying to grapple with what they're experiencing on a day-to-day, whether it's changes in their clinical practice, whether it's changes in their ability to complete their research? Do you have any advice or overarching messages to send to folks who are thinking through this?
Stephen Freedland: I mean, I wish I had great words of wisdom and sage advice. I mean, I think the one thing I think about is this in time will pass. And again, I don't know what that time frame will be, but this will pass. Life will resume at some level of normalcy in the future, and to make the best of it.
So one of the researchers I had talked to now with his lab being closed and really not as much to do, he and his girlfriend went to the Grand Canyon and said, "Look, there's nobody around." They're hiking. They're not going to the beach with thousands of other people. They're not going to the local public parks. But they've gotten out to explore the countryside in a place he had never been. And so taking advantage, his exact quotes, he sent me a text, I said, "Why weren't you at the meeting today that we had?" He's like, "I'm at the Grand Canyon. My girlfriend said when life gives you lemons, you make lemonade."
And so I think that's the advice for all of us in our own way to do things that this gives us an opportunity to do, that we hadn't planned on doing that. Whether it's seeing the Grand Canyon, writing that paper, reading up on some new surgical technique that you've been meaning to learn for a while, and really trying to be productive in that sense and to not get stressed and down, but really to try and keep moving forward.
Alicia Morgans: I think those are great messages that we as people, as clinicians, need to live for the moments that we have. Live slow if that's the way we want to do it, experience the Grand Canyon, get out where there aren't others, experience the world when we can't experience other people, and really take care of ourselves, both in mind and body as we move forward. And I sincerely appreciate your advice, your guidance as both a clinician, and certainly a researcher, and someone who's heavily involved in many of the things that we've read with prostate cancer and prostatic diseases. We appreciate your comments, and we look forward to catching up with you in a few weeks to see how things have evolved and changed.
Stephen Freedland: Yeah, no, I'd love that. And it is rapidly evolving for sure. So I think we're all adapting to the environment and so, we're all learning how to maintain productivity and sanity in this environment and health.
Alicia Morgans: Great. Thank you so much, Dr. Freedland.
Stephen Freedland: Well, thank you, Dr. Morgans.</div