The Impact of the COVID-19 Pandemic in Australia - Declan Murphy
May 12, 2020
Professor Declan Murphy from the Peter MacCallum Cancer Centre in Melbourne, Australia joins Alicia Morgans in this podcast discussion to share how his practice and his center have been affected by the COVID-19 pandemic.
Declan Murphy, MB, BCH, BaO, FRACS, FRCS, Urol, Professor, Consultant urological surgeon at Peter MacCallum Cancer Centre and the Royal Melbourne Hospital, Melbourne, Australia and Director of Outcomes Research at the Australian Prostate Cancer Research Centre.
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: The COVID-19 Pandemic Impacting GU Cancer Care in London - Tom Powles
View: COVID-19 and Genitourinary Cancers Videos
Read: Assessment of the WATChmAN (Web virtuAl Testicular CANcer Clinic): A Randomized Controlled Study to Estimate the Efficacy of an Electronic Surveillance Tool for Stage I Testicular Cancer
Alicia Morgans: Hi. This is Alicia Morgans, GU medical oncologist and Associate Professor at Northwestern University in Chicago, Illinois, in the United States. I am so excited to have here with me today Professor Declan Murphy, who is a urologist at the Peter MacCallum Cancer Centre and the Royal Melbourne Hospital where he does all kinds of exciting GU research and cares for patients with prostate cancer and GU malignancies.
Thank you so much for being here with me today, Declan. I really wanted to follow up with you and talk about how things have changed for your practice and your center as we find that COVID-19 is hopefully sort of ramping down but continuing on in this steady-state. I'm sure a lot is changing as it is changing all around the world.
Declan Murphy: I suppose, and as these scenes are playing out around the world, six weeks ago we were thinking, "Gosh. Yeah, we probably will get like that." So we had to, therefore, stop doing some stuff, even though we were fully staffed.
We stopped new clinical trials opening. That was a big impact. Trials that were about to have their start-up investigator meetings were put on hold. We also were scaling back recruitment into existing trials, stopping patients at the screening point, and so on. That was, certainly from a trial, from a research point of view, a quite immediate impact for us. And we've heard Tom Powles and others speak on your podcast at UroToday about the similar impact they've had and then how they're now slowly getting back to normal.
From a surgery point of view, I'm a urologist. We very much were having to look at a surge plan to say, "Okay, if that time comes and our staffing numbers drop and so on, what are we going to stop doing?" So, we had scaled that out. We had stratified patients to say what we would stop doing. But guess what? We haven't stopped doing anything.
I suppose that's been a great relief to us that we literally have not had to change anything we do, and that includes prostate cancer surgery for localized prostate cancer. It includes small renal masses, and so on, procedures that in your center and many other big western centers have been put on hold. And we were prepared to do that, but I'm pleased to sit here in early May and say guess what? No patients have had to have their procedures postponed, and we've had really no negative impact from a cancer delivery point of view, broadly speaking.
Alicia Morgans: That's wonderful. I hope that it continues that way, and I'm very glad because we've had many conversations over the last few weeks about how we really balance the risk of the cancer, which was real before and remains real for these patients really just facing this potential risk of COVID-19 as well. And if you're able to continue full force with the cancer therapies that patients need, that is really critical, but you, of course, had the flexibility to shift if you needed to.
You did mention clinical trials and delaying those site investigator visits, the start-up visits that we all need to really get trials off the ground. Have those resumed? Are you getting back to doing the trials that are so innovative and exciting coming out of the Peter Mac?
Declan Murphy: Well, they are, literally, just this week. One of the first things that happened when the surge planning was taking place was we moved almost all the research division in our cancer center, almost all the researchers are physically in the building, the new building we moved into a couple of years ago, but we very quickly moved them out to work from home and shut down all new experiments and so on. And from a trial point of view, everything was on hold. But guess what? Everything's back up and running now, which is a good thing. I think it reflects the changing impact of the disease in this country where, for example, community transmission in Melbourne is almost eliminated and so on.
But I think we also have to be prepared because one of the drawbacks of only having had 6,000 or 7,000 people in the whole country affected is that there is no immunity, and we certainly will be vulnerable to more waves of the pandemic in the future. It's probably one of the reasons why I think you won't be traveling down here anytime soon, Alicia. I think international travel in and out of Australia's going to be one of the last things that really starts going again at scale because one of the biggest risks to us is people bringing the virus back in here.
So I think yes, we're trying to do business as usual, but that's not to say we haven't learned a lot of lessons from the global community. And I must say, the UroToday podcasts have been really helpful to us in planning for what might have been a worst-case scenario.
I think the messaging we have to patients is very, very important, because patients are reading in the paper that stuff's going to be stopping, or they're reading that in New York there's no elective surgery happening, et cetera, et cetera, wondering, "Oh, is that going to happen to us?" And I think as a community of care providers, we have begun to learn how to communicate with these patients such that, for example, if we did have to stop doing prostate cancer surgery or small kidney mass surgery or so on, we had, I think, confidently prepared some messages for our patients so that they would understand it's okay actually.
For a lot of the stuff we do for the early cancers and so on, whilst they are significant, and we all agree they need some treatment, it's actually okay not to have that particular surgery this month, and it will be okay to have it at a better time in a couple of months time. So, I think we must do our best, in times that we all find nerve-racking and worrying, to try and have good communication with our patients so they understand that relatively small delays or even moderate delays for prostate cancer are okay.
Alicia Morgans: That's certainly the messaging that multiple groups in the U.S. and in Europe have been discussing, and so I'm glad that you already have that communication going with your patients. And it may be ... I don't know if you are preparing already for potentially another wave to come. What we in the U.S. think about and have been talking about is that as our summer comes, which is for some of us already started and for others, like here in Chicago, not quite here yet, hopefully, closer to June it'll be warmer here, we are hopeful that things may be a little bit better. But then, of course, as fall comes and winter, where flu in the U.S. starts to pick up again, there's also the concern, of course, that COVID-19 could pick up as well, and certainly then patients could get flu and COVID-19, which could be even more concerning.
You're moving into your fall and your winter seasons. Is this something that you think about? But it sounds like you've actually laid the beautiful groundwork and have plans to proceed through different phases if you have to, but is this something that you're thinking about with your patients?
Declan Murphy: Yeah, for sure, Alicia, and of course, many of us were interested in this typical cycle we see, that seasonal flu tends to go away when it warms up and so on. But out of interest, if you look, actually I heard a virologist commenting on this the other day, that in Australia we had our first cases of coronavirus in January because, of course, we're so well connected to China. Literally, as soon as there was a couple of cases in China, there were a couple of cases in Australia, I think around the 20th of January, which is at peak summer for us, so January, February.
And you might recall all these terrible scenes of fires we had in Australia. We had a particularly hot summer just gone by, but guess what? The coronavirus had no problem taking off in our summer and early autumn when the temperatures are very hot. In fact, our peak period of incidence growth, if you look at the curves, were from January up to mid-March, which is, guess what, summertime and early autumn growing numbers, and here we are coming into winter and numbers have dropped off because of social distancing. So, I think a message in there is that I don't think we can presume this particularly very contagious virus is going to be as susceptible to either the benefits of it warming up that we might've presumed.
I suppose that brings us onto the social distancing side of it, which has been very effective in our country and seems to be effective whenever you do start it, and it's important to start early. And I think that's going to be a legacy, isn't it, for quite a while to come that even if the numbers get wiped out as you warm up in Chicago, I think you're going to find that it's not going to return to life as normal, even if it returns to kind of business as normal in the big center you work in at Northwestern.
I suppose as colleagues and parents and children, we will be adapting to a different type of summer, and the one you face into, it will certainly be socially distanced, I think.
Alicia Morgans: I agree. And thank you also for clarifying that certainly this virus, despite different messaging, does not seem to be so sensitive to winter versus summer. I think the concern in the U.S. is that as flu picks up, people may be just more vulnerable and that coinfection could be a challenge. But I do agree with you and hope that social distancing here, as it has in Australia, will reduce that number and that we've learned, hopefully, by the fall. We know how to social distance. We know how to protect ourselves, that things will be better.
One thing, as we start to wrap up, that has been very important, and you mentioned earlier, is this telemedicine, this remote care of patients has become really standard here in the U.S. It sounds like it's also standard for you in Melbourne. In a place like Australia, with such vast expanses and people that could be cared for being so far away geographically, do you find that this might be a silver lining that is a way hopefully and potentially for you to care for patients who need services? Certainly not surgeries. You can't do that from a distance. I wish that you could. Maybe someday. But to provide more care for those who do have themselves so separate from you because of the geography of where you live?
Declan Murphy: Oh, for sure. Don't we all feel that? And it is important to have a silver lining to look forward to, but good things always come out of these types of big events. And I think that's just something we'll look back to in years to come, or indeed our next generation of residents will sit with their mouths open thinking, "What? The patients used to come into the office all the time for their followup appointment?"
They'll find it hard to imagine that because I think especially because it's not just a short period, Alicia, where it's just three or four weeks of disruption. It's going to be a whole long period, year or two, so we're all going to really adjust to this, patients and clinicians at all levels, and I think we'll take it as a legacy. And in Australia, as you say, we're a big country, so we've always had some significant embrace of telehealth as the technologies have allowed.
But to give you an example, at Peter Mac, the cancer center we work in, which is a big tertiary-level center, people come in there for trials and specialist treatments. At the start of March about 5% of our consultations in the outpatient department were by telehealth. And now, last week I think 70% were telehealth. So, that's great, isn't it? And I must say, we've all adjusted to it.
I might ask you, as an oncologist looking after a lot of patients with advanced disease, about this very topical area of breaking bad news on telehealth. We've read a lot about this on Twitter, and I've seen people making comments that yeah, telehealth is great, but when you have to have these breaking bad news conversations, I'm not comfortable with that. I prefer to have the patient in the office with me.
But I had a fascinating, again, conversation on our podcast, on GU Cast, a couple of weeks ago with somebody who gave us a totally different perspective. We were chatting to Rob Hamilton, a urologist in Toronto, who's actually done a randomized trial of telehealth in testes cancer patients in the pre-COVID era, testing what the reactions of patients were. Now, granted these are younger patients, but also they are receiving bad news on some occasions with metastatic disease. And they made the comment that they often feel more comfortable receiving bad news in their home surroundings rather than, for example, receiving it in a doctor's office, and then go back out to the waiting room and pay for your parking ticket and so on, that we as clinicians should not presume that because we feel the best place to deliver bad news is in our office because that's where we always deliver it and we're used to that.
We should also consider how the patient is receiving the bad views and the type of environment they may feel more comfortable, and chances are, guess what, it's not going to be in a hospital waiting room in a big public clinic. It may well be at home with a loved one. So, I think we're all going to, even in areas we might find uncomfortable now, adapt to telehealth and understand that this is going to be one of the best things that comes out of this crisis.
Alicia Morgans: I think it's so interesting that you mention that, and I will have to look up that study on telehealth in testicular cancer patients discussing bad news because there's actually a palliative care telehealth study going on right now. It's just launching at Northwestern, I think at several other sites, to evaluate this very similar thing. Where do patients feel most comfortable? Are we most comfortable delivering bad news in our clinic in face-to-face fashion because we're actually quite comfortable in that setting? That's our home in a sense. That's where we have our support system. But patients may actually prefer to be able to cuddle up in their bed after they're done hearing some bad news and turn off the phone or the viewer and just take a minute to themselves or be in their own home, their own comfort.
So, you make a very, very good point, and I think that it's important for us always to remember that just because we're most comfortable, or we think that this is the right treatment, or we think that this is the patient's preference that they are unique and different people than us. Right? And that their comfort and their preferences may be completely different than we realize, and if we don't ask, we won't know. I definitely look forward to that, and thank you for raising that very, very important issue.
Thank you as always, Declan, for sharing your expertise and your insights. I do hope we can catch up with you at some point in the future and hear how things continue to evolve. And I wish you the best of luck in your continued care of patients, your training of residents and fellows, and your amazing clinical trial work really advancing the field for all of us. Thank you for your time today.
Declan Murphy: Thank you.