Expanding Access to GU Cancer Care Through Telehealth and Prioritizing Systemic Therapies for Genitourinary Malignancies - Srikala Sridhar

May 12, 2020

Recorded Date: April 27, 2020

Alicia Morgans is joined by Kala Sridhar from the University of Toronto to discuss the impact of COVID-19 on her clinical practice. Six weeks into social distancing, Dr. Sridhar discusses the impact isolation has had on both the patient and physician. Dr. Sridhar brings to light a unique perspective of telehealth and its potential to experience transformative changes in the setting of COVID-19. 

In addition, Dr. Sridhar highlights some of the recommendations or guidance that are discussed in a recent rapid communication published in the Journal of the Canadian Neurologic Association, "Prioritizing systemic therapies for genitourinary malignancies: Canadian recommendations during the COVID-19 pandemic". 


Srikala Sridhar MD, MSc, FRCPC is an Associate Professor within the Department of Medicine, Division of Medical Oncology at the University of Toronto. She is head of the genitourinary cancers medical oncology site group at the Princess Margaret Hospital and treats primarily bladder, prostate, and kidney cancers. She has an active research program in the area of bladder cancer, evaluating new therapies and imaging modalities; and is currently the international study chair of a National Cancer Institute of Canada (NCIC) phase 2 clinical trial. In 2011, she was recognized for her teaching excellence with a University of Toronto teaching award.

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, my name is Alicia Morgans, Associate Professor of Medicine, and GU medical oncologist at Northwestern University in Chicago, Illinois. And I am so pleased to have here with me today a friend and colleague, Dr. Kala Sridhar, who is an Associate Professor of Medicine, and the Chair of the GU Medical Oncologists of Canada. She practices at the Princess Margaret Cancer Centre and is part of the University of Toronto faculty. Thank you so much for being here with me today, Kala.

Kala Sridhar: Thank you, Alicia. It's nice to chat with you.

Alicia Morgans: Wonderful. So, Kala, you have so many roles and have your hands on so many things, I sincerely appreciate always your perspective and your broad scope of things. Today, I wanted to talk with you about the impact of COVID-19 in your practice, and how the feelings of isolation, both on the part of the patient feeling isolated, as well as the provider feeling isolated, have impacted your practice, your day-to-day. And how you see that changing the practice that you have at the University of Toronto.

Kala Sridhar: Yeah, it's a great question. So I think we've been now about four to six weeks into this social isolation, and it's certainly having impacts, both on patients and physicians, as you've said. From the point of view of patients, we are tending to see most patients by telehealth, or virtually. And for the most part, I think it's going well.

So I think patients appreciate the fact that they don't have to get in their car, they don't have to drive, they don't have to park. And they can see us really from the comfort of their own home. When it comes to doing labs and investigations, many of those are being done close to them as well, so they don't have to come into the cancer center. So I think there are certainly some positives.

But the challenges are also becoming evident. So a couple of the challenges that I've really noticed, is the fact that when you see a new patient, you really miss that face-to-face connection that you can build when you see the patient the way we're used to seeing a patient. The other setting where I find it's more challenging is when you're discussing difficult end-of-life type issues. And again, it's a setting where you want to see the other person, you want them to see you. And I think that is a little bit more challenging in the current times.

And then certainly for patients who are admitted to hospital, we, and many other hospitals, have adopted the no visitor policy. This means that patients don't have the key support that they're used to having, their family in the hospital. The doctors and nurses, of course, are there and taking care of them, but they're not having their physically present with them. And I think that that creates a number of challenges.

And I think, because of that, sometimes patients really don't want to come into hospital, which can be a problem if they're sick, and do need to come in. And then others, once they're admitted, they really want to leave quickly. So they don't really want to be in a hospital. They want to try and be discharged as soon as possible. So I think those are some of the challenges we're facing when we deal with patients.

Alicia Morgans: Absolutely, and certainly as we try to deal with those relationships that are so critically important in oncology. And one of the other things that I know you've tried to tackle with actually many of the GU oncologists in Canada, through a recent rapid communication, in the Journal of the Canadian Neurologic Association, is how we think about as GU medical oncologists, prioritizing systemic therapies for the cancers that we treat right now, as we're dealing with COVID-19.

And I'm just wondering if you can walk us through some of the recommendations or guidances that you debated and discussed, as you put together that rapid communication with all of the other oncologists who are on that publication?

Kala Sridhar: Yeah, I mean I think it was important to have a publication like that, to connect with our colleagues both in Canada and outside of Canada. And even one day maybe to compare practices, and then how the outcomes were impacted by perhaps changes that we have implemented during this time of COVID.

So some of the key things that we went over was the fact that we need to ensure, wherever possible, to not compromise the care of our cancer patients, because cancer is not stopping for COVID. So we discussed the fact that there are certain situations, like testicular cancer, for example or neoadjuvant chemotherapy for bladder cancer that should not be delayed despite the COVID situation.

Other situations perhaps can be delayed by a few weeks, but we fully recognize that this is very, very difficult for patients. And I think that we try very hard in the guidance document, really to try to ensure we are balancing the need for cancer care with the challenges we face in terms of bed availability, potential shortages, and shortages maybe even of drugs down the line.

And so I think we try to balance all those considerations. In some settings, for example, in the setting of bladder cancer, which of course I am the most familiar with, surgeries are not currently happening. So I think it really puts the focus back on something like neoadjuvant chemotherapy.

And moving forward, if surgeries continue to be offline, I think we're going to have to explore things like concurrent chemoradiation for bladder sparing. So different strategies may need to be looked at, to try to manage our patients during this time.

Some of the other considerations as well include things like looking at the use of dexamethasone, which you use across the board for many chemotherapies. Could that, and does that, potentially increase the risk for COVID through its effects on the immune system? Whether we should be using more GCSF to try to prevent patients from developing neutropenia? Perhaps primarily so they don't have to go to the hospital where the risk may be higher. And we don't really know if that strategy is going to prevent people from developing COVID, which of course is viral.

And then the third thing that I think I felt should have been included in that document is really a discussion about end-of-life issues because we know our patients are vulnerable, we know from the studies in China that cancer patients did have slightly worse outcomes. And as such, if one of our patients were to be treated and end up getting sick and being in the ICU, it's really, really imperative that we understand their goals of care and what they want. Because we may not have an opportunity to discuss that later on. So I think it really put the onus on us to bring those conversations back to our patients today.

Alicia Morgans: So, and I think it's a wonderfully complete document, and a nice way for us as medical oncologists, regardless of where we live, to understand the thought processes of the focus in Canada. And also to, I think, adapt and use a lot of those for wherever we're practicing. So kudos on putting that together.

And I wonder if some of this telehealth, virtual care practice that we have all adapted now that we're in COVID-19 when we have to, or in those settings where it's appropriate, is something that you envision may be important for places like Canada?

Certain provinces certainly have few medical oncologists, and great distances, geographic distances, for patients to travel. Or certainly other areas in the United States, there are areas that are very rural and hours away from potentially academic centers, or other large centers with GU medical oncologists. Is this something that you think may impact care delivery over time in places like Canada or elsewhere?

Kala Sridhar: Absolutely. I think that telehealth virtual medicine is going to be transformative to the practice of cancer medicine. I think many of our patients do appreciate the opportunity to speak with us without having to leave their homes. And some of them indeed are sick, elderly, frail, or potentially, as you say, live very far away from a cancer center. So I think it's really pushed us towards virtual health. And I think we'll get better at distinguishing where we can do virtual care and other circumstances where it's almost better to see the patient and bring the patient in. Because of course, we're missing the critical component of a physical examination. But I absolutely think that this is going to continue going forwards.

The other setting where I think we've seen some interesting changes, and perhaps some relaxing of criteria is in the area of clinical trials. And it would be interesting to see if some of these changes, in terms of allowing patients to be seen virtually, having their blood work done at their local labs, perhaps even having scans done closer to home. If some of those strategies, if applied going forward, may increase the ability of patients to participate in clinical trials. And perhaps this may specifically be beneficial to the elderly patients, where we know are quite underrepresented in clinical trials. So I think that there are going to be some transformative changes, and I think some for the better. And in some ways, COVID has pushed the gas pedal on some of these changes coming into effect.

Alicia Morgans: I love that, Kala, and I know that really ensuring that clinical trial eligibility criteria are certainly robust, but are also flexible enough, or lenient enough, to allow patients who really represent those patients that we treat on a day-to-day basis. Whether they're elderly, whether they have some degree of organ dysfunction, to participate in those trials, whenever safe.

And I love that you see this as an opportunity to potentially think about making that more possible for our patients, both maybe at the time of eligibility, and then also increasing participation by flexing things a little, or making them a little less strict in terms of followup. And I look forward to some publications that I am sure you will be writing, as this time goes on, to help us think that through. Because I think that's a very wonderful thing that could come out of all of this.

So as you're thinking back over the last few weeks, month and a half or so, of really dealing firsthand with COVID-19 in your practice, do you have any messages or any thoughts or lessons that you've learned that you wanted us to all think about as we move forward.

Kala Sridhar: Yeah, I mean I think a couple of lessons. I think communication and staying connected is important. Both for us as healthcare providers, but also for our patients. I know when I speak to many of them, the first few minutes are just catching up, because I think there's a lot of isolation, and there is some loneliness out there. And so I think I can't overstate the importance of good communication. Building that relationship, even if it's through a phone, or virtually. I think it's really, really important.

I think between colleagues it's important to check-in. I think everybody is facing different challenges. Certainly, some people have family who is out of town. They're not able to see their family, and sometimes those are the supports they need to get them through the day. So I think recognizing that we really need to come together as a community, as colleagues.

And I think we're also aware that we're not going to meetings, and we're not sharing knowledge, but also having the social benefits of meeting with colleagues and the like. And so I think that it's really important that we keep up communications, and when we're doing video calls that we should really try sometimes to turn on our video, and so we know other people are out there.

So I think really simple things, and then the usual things like make sure we eat and make sure we sleep and make sure we exercise. And try to follow into some sort of a pattern in these unusual times.

Alicia Morgans: Well, thank you. Thank you so much for sharing those thoughts, Kala, and certainly thank you for sharing your time. And we look forward to following up with you again. Like I said, I really do look forward to seeing the work that comes out of this in terms of ensuring access, or perhaps expanding access for patients who are involved in clinical trials, both at the eligibility time point, and then all of those follow-up time points. And we of course sincerely appreciate your [inaudible] malignancies. Thank you so much.

Kala Sridhar: Thank you so much. Have a great day.

Alicia Morgans: You too.