Alicia Morgans: Hi, this is Alicia Morgans, GU Medical Oncologist and Associate Professor at Northwestern University in Chicago. I am so honored to have here with me today a friend, Dr. Fred Saad, who is a Professor and Chief of Urology at the University of Montreal Hospital in Canada. Thank you so much for being here with me today.

Fred Saad: My pleasure, Alicia.

Alicia Morgans: Well, Fred I appreciate you taking the time because I know in your leadership roles at the university, you've had a lot of struggles in the setting of COVID-19 as we all have, certainly not unique to you and what you're dealing with, but I'd love to hear how you and your team are adapting to what you're facing on a day-to-day basis and in the setting of this COVID-19 pandemic. Can you share what you've been experiencing?

Fred Saad: Sure. So I think we're far from being unique. I think this has become a worldwide situation depending on where people have started or what countries have started to be affected, it's clearly changed over the last few weeks. So we really started to get affected at the beginning of March, we started to see the first cases. I think we reacted quite quickly. Within around the middle of March, we started insisting on confinement coming back from trips and all the rest. And very soon after in the hospitals, we had to make the decision about how to prioritize patients because clearly we couldn't have a system business as usual, whether we're talking about urology in terms of surgery, and followups and clinic, or GU oncology that I have to manage also in terms of chemotherapy and our systemic therapies as well as radiation oncology. So we've clearly over the last two weeks especially have had to make really difficult decisions in terms of who we operate.

We have to really limit surgeries into the highest risk patients, the ones most likely to suffer if delays are prolonged. And we've always had delays, but we've managed. But now, we've clearly limited to cancer cases that both have a high likelihood of cure and would be harmed with further delays. And so these have been struggles. So patients that are going off to robotic surgery were most often the ones with lower risk or intermediate-risk prostate cancers, they've been put on hold and they're probably going to be on hold for the next three months, which is the reality. And then large kidney cancers, invasive bladder cancers, especially if they've gone through neoadjuvant chemo are really the priority that we've placed as well as the very high Gleason scores, in the eights, especially nines and tens that we still see for surgery or radiation therapy.

So we've had to make those difficult decisions as many other centers have had to evolve over the last few weeks.

Alicia Morgans: So just a couple of questions to follow-up on that. And this is not because I'm quizzing you certainly, but really to get your opinion and your institution's opinion on a couple of things. And one of those that we talked to ... I actually talked to a colleague earlier about, is this whole decision around neoadjuvant chemotherapy, yes or no, surgery, and how we time other modalities of therapy around surgery for patients with muscle-invasive bladder cancers. And certainly, if a patient's had neoadjuvant chemotherapy, you can proceed with surgery after that. But when you have a new patient, new muscle-invasive disease, what is your treatment algorithm or your decision process around ordering treatments for that patient?

Fred Saad: Yeah. So for now, obviously, the common answer is it's a case by case, but if we talk about generalities, we have taken the decision to stop neoadjuvant for the average patient and go straight to surgery, assuming that those patients are fit for surgery. And it's also the question of, is the cancer more at risk or is there more of a risk of catching COVID-19 and succumbing to that illness? So for now, I think for the majority of muscle-invasive bladder cancer, there's more of a risk of delaying surgery indefinitely. And for chemotherapy, the average patient that we're operating is not getting the neoadjuvant at this time, even though we have strong components of neoadjuvant, except if we feel there would be inoperable without the neoadjuvant chemotherapy. So I would say for now, pretty much everybody's going straight to surgery that's operable within a delay that's unfortunately much longer than we would prefer.

Anything in terms of non-muscle invasive is being put on hold except for the very highest risk patient that looks like they might have an invasive disease or those ... unfortunately, TURBT are being delayed. And we're probably going to be using a bit of the UK strategy where we might go straight to a cystectomy if it looks like it's clearly invasive, had skipped the TURBT altogether as long as we've confirmed that they'd got bladder cancer, which is one of the ways of reducing time and use of resources that are becoming too precious in the operating room.

Alicia Morgans: And that all makes a lot of sense and certainly, others are making similar decisions. I'm just wondering, and this is as much for the listeners as for me in my practice, for those patients who are not getting their neoadjuvant chemotherapy upfront, are you circling back with those patients after recovery and planning to do adjuvant therapy? And I guess the answer could be we're planning to now, but we don't know what time will tell because we don't know exactly when this pandemic is going to die down. Is this an indefinite hold for chemotherapy or are you planning to do adjuvant in the near future?

Fred Saad: I think we're planning to do adjuvant in the near future. Like you, we do oncology, so we are fundamentally optimists. And I'm hoping that within the next three months we should be getting back to a more sane way of doing medicine. And so we should still be in a window where adjuvant would make sense in patients that require it. So we haven't stopped doing chemo altogether, but we're constantly asking the question, is it safer for the risks of chemo in the face of COVID, or is chemo clearly going to benefit of this patient? Because we have to avoid the collateral damage of all of this. I don't want to see more patients die because of delays or inadequate treatments than patients that are dying from COVID disease.

And patients have told me that. This week I saw a large adrenal gland that clearly is cancerous. And I told the patient it's going to take several weeks before I can actually operate her. And she was completely flabbergasted because she was sent from another physician knowing that it was urgent to do her adrenal cancer, but this is the reality. And she recognizes she might be collateral damage and she'll die because of the COVID-19 situation but not because of COVID-19. And so this is really worrisome for us that are in the front lines.

Alicia Morgans: I completely agree and really appreciate the thought process because particularly as I think about neoadjuvant chemotherapy in my own practice, I always think of neoadjuvant chemotherapy as being the icing on the cake and adjuvant chemotherapy too if we haven't had the opportunity to give that before the surgery for muscle-invasive bladder cancer. But the cake, the thing that's really the definitive therapy that's going to make or break this treatment algorithm for this patient is the surgery. And so if you have the opportunity to do the surgery now that makes total sense. And there is a significant risk to giving the chemotherapy even if you don't have the operating room now, there's a risk to giving neoadjuvant chemotherapy in the middle of a pandemic. And you may make some patients ill to the point that then they are never able to get their surgery. So it is all decisions about risk-benefit and ultimately trying to care for the patient above all else.

So I really appreciate thinking through this. It is also interesting to hear your thoughts on how patients not infected by COVID are still affected by COVID and can still be collateral damage. We actually had someone speak the other week about how all patients are ultimately affected to one degree or another because we do recommend in many of our guidelines that patients always consider a clinical trial for their treatment, and many patients do enroll in clinical trials. But right now, at least at our center, clinical trials for the most part for many practices are on hold more or less, not necessarily cancer center-wide, but investigators are really hesitant in some cases to put patients on. And of course, there are decisions that patients are making too, how are your clinical trials fairing in the face of all of this?

Fred Saad: Well, clearly we've taken the same approach both for ethical reasons, but also for reasons that are ... these patients, many of them are over 70, which is the really high-risk population. And anything that increases traffic in the hospital is clearly discouraged. So we are still continuing clinical trials. We're trying to limit patients who are on clinical trials from coming in and out of the hospital. So we've gotten authorization for some clinical trials that patients come actually to the front door of the hospital and the nurse gives them their medication, and we just skip the physical exam as long as we talk to them with telemedicine, see how they're doing, how they're feeling, how their blood pressures are, all the rest. And trying to do everything we can to avoid having these face-to-face visits to a minimum.

And then in the face of no other alternative for a disease that is very aggressive, we're still allowed to put patients in clinical trials, but we have to absolutely limit the physical presence of patients in the hospital to limit the risks for them of catching COVID-19, but also for the staff of being in contact with people. Because right now we don't have that much in terms of prevention based on the data, not everybody's covered. And we would not have enough individual protection to cover everybody just in case patients walk in unknowingly with COVID-19. So this is a major issue for clinical trials, and I'm sure we're going to recover, but this is going to have longterm consequences. It's not that easy. And there are clinical trials that were supposed to start that are all on hold, that are going to have tremendous impacts on how early we're going to be able to report over the next months and years.

Alicia Morgans: That's true. And I am glad, I'm so glad to hear though how your center has adapted. And one of the ways that we're all adapting, and one of the successes that may come out of this because I think there have to be some successes while we struggle, is that our ability to do more remote medicine, telemedicine, I think has really blossomed even in centers where this has not been on a radar, were on the radars of most clinicians to find that we are able to successfully do this and in many centers, across the country, across Canada, around the world, has just been something that I've been so proud to learn about. And I'd love to hear your experiences with telehealth and telemedicine via telephone, via web. How are things going for you in your practice?

Fred Saad: So I think many of us have pushed to have telemedicine accepted as a way of following patients, a way of recognizing that as being a valid way of interacting with patients. And it took this unfortunate situation for this to become a reality and we're realizing it's an extremely effective way of following patients, interacting with patients, with the benefits of limiting patients from missing work. Right now, obviously many of them are not working because of the situation, but coming into downtown Montreal, losing time from work, parking, all the rest, just for something that could be done by telemedicine, I think is tremendously important. And we can do a lot more than we would've imagined now that we're obliged to do it. And it's appreciated by both patients, their caregivers, they obviously can't replace face-to-face, but if it can replace one out of two visits, that could be beneficial for the healthcare system for the patient's quality of life.

Because we talk a lot about quality of life, but parking in downtown Montreal, it diminishes your quality of life both financially and socially. So this is the same with many large cities, with large cancer centers. So I think we're going to learn from this and probably grow from this. I think we're underutilizing the telemedicine with visual communication. And I think that's going to continue to grow and if we can actually see patients like we're able to do now, communicate with them, because sometimes they say one thing, but looking at them, we realize that they're not entirely honest in what they're answering. And so we still need that contact, at least visually. And technology I think is going to help us to do a better job and we might actually be able to communicate more often than we can when we force them to come in for visits.

Alicia Morgans: I agree. And it's nice too for us to have that opportunity to stay connected with caregivers, loved ones, others in the family who support the patients, because at least at our center, we're limited to just the patient himself or herself in the room at this point and no visitors, except in extreme situations where we have clearance for a second person for only certain reasons. And so this allows us to kind of communicate with everybody, and like you said, to hear kind of the behind the scenes from the loved one or the caregiver of the patient himself or herself isn't always able to share the whole story of what life is like. It's nice to have that other person say, "But you forgot to say that you were having intractable pain yesterday, or you haven't had a bowel movement in three weeks." So it's nice to hear that other voice sometimes.

Fred Saad: Oh yeah. And that hasn't changed. A lot of the times it's the wife that's answering the question then I have to interrupt if I can talk to her husband a little bit. This still goes on and like you said, that's a great point, that right now patients are not allowed to be accompanied when they come to the hospital. So this is a way of being able to actually talk to the significant caregiver or significant other in the patient's life.

Alicia Morgans: Absolutely. So if you had one message to wrap up our conversation from today ... and I think that we will have to touch base again and in the next few weeks because as you said, things are changing rapidly. But to wrap up for today, what would your message be to the listeners?

Fred Saad: I think the main message is to be reassured that patients are being treated in the best possible manner that we can offer right now. And then I think all of us that are dealing with cancer care are trying to ensure that we do things safely. So I'm very hopeful that very few patients are going to be harmed by these delays that are inevitable. So I'd like to reassure because I think a lot of people are living with a huge amount of stress and I just want to reassure that for the vast majority this is a difficult time, but in the long term, they won't be harmed because of this.

Alicia Morgans: I think that's an excellent message and one I would echo wholeheartedly that we are working together. We will all get through this together. We'll come out on the other end and there will be pros, there will be cons, but we will be stronger for it and we will take care of you all in the interim. Thank you so much for sharing your time today with me, Dr. Saad.

Fred Saad: It's a pleasure.