The Rapidly Evolving Impact of the COVID-19 Pandemic on Managing GU Cancer Malignancies in New Orleans - Oliver Sartor
April 29, 2020
Oliver Sartor joins Alicia Morgans from New Orleans, Louisiana providing an update on the current healthcare environment during the COVID-19 pandemic At the Tulane Cancer Center, they have begun using new technology that allows rapid testing for COVID-19 in-house, receiving results in as little as five minutes.
A. Oliver Sartor, MD, Professor of Medicine and Medical Director, Tulane Cancer Center; C. E. and Bernadine Laborde Professor of Cancer Research, New Orleans, Louisiana
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.
Watch: COVID-19 Impacting GU Cancer Care in New Orleans at Tulane Cancer Center - A. Oliver Sartor (Recorded: March 19, 2020)
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 excited to talk today with Dr. Oliver Sartor, who's a Professor of Medicine and the Medical Director of the Tulane Cancer Center in New Orleans, Louisiana. Thank you so much for being here with us today, Dr. Sartor.
Oliver Sartor: Oh, thank you, Alicia. It's a delight to be here under these strange times.
Alicia Morgans: They definitely are strange times. And we were talking offline just a few minutes ago about how they're not just strange now, they've evolved so quickly. Even from our last conversation, things are so different. So what have you seen changing at your center?
Oliver Sartor: Well, I mean first of all there, I think there are several pieces of good news, and I always like for people to hear the good news. Number one is that our admissions are down. Our discharges exceed our admissions by a substantial margin right now. The city of New Orleans has taken to heart the recommendations for social distancing and isolation, particularly in the older patient population, and it's really making a difference. Now the virus is moving out into the more suburban regions, and into the more rural regions. It hit New Orleans first, and it hit New Orleans hard, but we seem to be past the peak. So that's important, and I want to convey that.
Number two, we actually do have the rapid testing for the virus in our cancer center now, so it's a 15-minute turnaround. We actually get a positive in five minutes, and a negative in 15. And we've instituted testing for those with hematologic malignancies at those undergoing chemotherapy. Good news, we've tested about 80 patients so far, and I've only had one positive, so that's good. And we also have the plasma phoresis protocol, where patients who recovered from the COVID-19 can donate their plasma through plasmapheresis, and then have it re-infused. And our protocol for that is up and going. And we've treated our first patient last week. So lots of evolution in terms of rapid testing, in terms of a new therapy potentially, and in terms of really bending the curve, which we have done here down in New Orleans.
Alicia Morgans: That's fantastic. And I think all of these initiatives are so exciting and important, but can you talk to us a little bit more about the rapid test? Because I think that that hopefully will be coming to centers across the nation, and some form of some type of rapid test, I imagine will become internationally available. How are you implementing this best in your GU oncology patients, recognizing that we can't test everybody, probably? Of course, there are still limitations on the test availability, and it sounds like you're doing this mostly in those patients getting chemotherapy. So, what are your standard operating procedures around that, and how do you optimize that in GU oncology?
Oliver Sartor: Sure. So first of all, just about the logistics. So, this is an Abbott rapid analyzer test. So, it's distributed through Abbott Labs. We obtained at Tulane five of these rapid analyzer testing machines. And of course, it comes with the swabs, the transport media, et cetera. And we had one dedicated to the cancer center, and the capacity was about 25 per day. So when we sat down with infectious disease, and with the other personnel leadership in the cancer center, we had to make a decision about how to allocate 25 tests per day maximum. And so what we did is, first of all, prioritize the hematological malignancies. There's no doubt that the mortality rate, at least in our center, is high for hematological malignancies. It's much lower for the solid tumors. But then among the solid tumor patients, who would we prioritize? And we decided to do only those patients that are receiving chemotherapy.
So we also, of course, made it an option for the patient to receive it. We cannot require a patient to do a test that they do not consent to, but the vast majority of our patients have consented. The other thing is, for symptomatic patients, we have a different algorithm. So only the patients that are receiving testing are those that are asymptomatic for solid tumors, and GU malignancy included. That would include chemotherapy or infusional immunotherapy. And what I can say is, out of our tested patients of about 80, that it's only one positive so far in hematologic malignancy, so our priorities may actually shift because we actually have a little additional capacity that we can utilize. And tomorrow we're going to have a discussion about potentially screening all the radiation oncology patients, the underactive treatment, because those patients were repetitively coming into the cancer center, and they have more exposure risks for our personnel and other patients. So right now we started with chemotherapy and GU, but we're going to probably morph into including more patients, including radiation, quite soon.
Alicia Morgans: That's really, really helpful to think about, and I think that as we all are moving forward, and we have access to that test, we will have to think about these implementation challenges, and it does make sense to expand that maybe even once a week, or whatever it is to this radiation oncology population, because those patients, as you said, have just so many touchpoints with the health care system, and all of the personnel that are related to that. When you have patients who have symptoms though, that's really, like you said, for your asymptomatic population, how are you handling those patients? Are you testing all patients? Are you asking them to delay when they come back? And if they do test positive, what are you doing in terms of getting them back into the medical center after they are presumably well again? So, what are your thoughts on that?
Oliver Sartor: Yeah, great question. So we do have an algorithm for those that are positive for febrile, and every patient has a questionnaire when they come to the clinic. We are, by the way, restricting traffic. We're not allowing additional visitors. The patients have to come on their own unless there is a very good reason for a spouse or supportive other to accompany them. For instance, if they're not able to get around by themselves, or have some mental or emotional issues that require support. So first of all, we really restricted the visitors, and we're screening everybody who comes into the center.
If someone is symptomatic, they are referred to their physician who will do a disposition. If there is reason for concern, then there ... and for instance, I'll give you an example of a patient who was symptomatic that I did allow in. His symptom was shortness of breath, and of course, that could be a COVID symptom, but I knew that this patient was profoundly anemic and that we were actually considering a blood transfusion. And so when he described exertional dyspnea, and I questioned him, and it really wasn't a cough or a fever, it was really shortness of breath, which they picked up on the screen, but we did not require him to go to the unit for testing. We do have a dedicated facility for those who are symptomatic and have a clinic that is set up very specifically to assess the infected patients. So, that would be a separate algorithm for the patient who's symptomatic versus the asymptomatic patient.
Alicia Morgans: Very, very interesting, and really helpful, actually similar I think to what we're doing here, and I'm glad for your anemic patient that you used your medical judgment, and your team used their medical judgment to figure out what's most likely in this situation. Because that can be really challenging in our cancer patients, and it is really important for us to not just use checklists, but to use our clinical acumen at the same time to make sure that we get the right treatment and the right understanding of what a diagnostic situation could be to those patients.
Oliver Sartor: Yeah, we're trying to empower the physicians to be involved in the decision making instead of leading it to the screening personnel to really make medical decisions. We're trying to ensure that the screening personnel screen the patient, but if there are issues or questions, then it comes back to a physician in order to make a clinical decision.
Alicia Morgans: I think that makes a lot of sense, and I'm sure it's being implemented elsewhere, too, because of that. If you have a patient who has tested positive and has been at home, is recovering, what are you and your team doing about bringing them back into care, and trying to make sure that they really don't lose out on the medical treatment they need for their cancer as well?
Oliver Sartor: Yeah, that's a really tough question. So the CDC has given guidelines with regard to the resolution of symptoms. We have not had this situation arise since we have our rapid testing availability. What we would do, now that we have the rapid test, is to test that patient to ensure that they've cleared the virus. Otherwise, there has to be a balance between. And I can give an example of one of my own patients who was infected. He was receiving radiation therapy and hormonal therapy and became symptomatic, was diagnosed with the virus, unfortunately, had to be admitted, but thank goodness he's okay. He's now been discharged. We're continuing is hormonal therapy, which we can do with little risk, and then holding the radiation therapy until some undefined period. I could bring him in right now, but I'm actually choosing not to, given the fact that there are a variety of other factors that could be involved with him being on hormonal therapy. I actually feel safe that his disease is under control. I'll bring him back for testing next week, in order to ensure that all his parameters are as expected. But I'll restart radiation at some point, but I haven't actually decided exactly when yet.
Alicia Morgans: So you bring up a great point. That rapid test is going to be so useful to us in our practices, not only as we see asymptomatic people, but as we're trying to bring back patients who are asymptomatic now, but we believe have recovered. That will be really helpful. And the other thing that is on the horizon, or at least we hear that it should be very, very soon, and it seems to be present in some places, is an IGG type test, a test to look for patients, or for healthcare workers who have been exposed now have antibodies against the COVID-19, the virus. So, are you anticipating integrating that into your paradigm at some point?
Oliver Sartor: Yes. It'll probably be through protocol. I've been in discussion with the infectious disease team on that very point. They're not quite ready to have the antisera testing, and there will be some degree of uncertainty because the presence of antibodies and the presence of true immunity are succinct. You can't just extrapolate for the presence of an antibody to ensuring that the patient is actually immune, and will not catch the virus. We believe from the basis on other coronaviruses, and there are some interesting experiments that I read about in the past week, where there have been intentional exposure of coronaviruses on a repeated basis. And in fact, the patients who did develop good antisera were immune to re-challenge, but that, of course, was not this particular coronavirus where we really don't have experience. I'll just simply say I'm looking forward to the antisera test. I'm a little bit cautious in the interpretation, and how it relates to immunity, but I think it will, provided that the sensitivity specificity is verified, give us tremendous insight over understanding who has been infected. And when we know that, I think it'll be a big step forward.
Alicia Morgans: I could not agree more. And thank you so much for reminding everyone that just because someone appears to have been infected before, we actually at this time don't yet know that that confers resistance to future infection. I remember reading a few weeks ago, maybe even a little longer, about a woman in Japan who had been infected and then who subsequently had been infected again. And who knows what her individual situation was, or any of the criteria around that diagnosis, and diagnosis again? But I do think it is important for all of us to remember that as we're thinking about these plans in our own practices. So as we wrap up, are there any overarching themes or any messages that you want to send to folks who are listening, as we're all trying to continue to move forward with our new normals now?
Oliver Sartor: Yeah, I continue to believe that social isolation, social distancing, is appropriate for our cancer patients. I do not think that they ought to take this virus lightly. I think that we will begin to hear about clinical trials probably in the next several weeks. The prospective randomized trials that have been instituted, I think those are going to be very critical to understand because if there's a treatment available, it'll be a game-changer. Right now, in my opinion, there is no therapy that has been proven. And I think that isolation and distancing and care about your relatives, care about your spouses, care about your family is really the critical thing to keep in mind right now.
Alicia Morgans: I could not agree more and I thank you so much for your time, and your expertise sharing your experience. Thank you so much.
Oliver Sartor: Thank you, Alicia.