Strategies For Treating Genitourinary Cancer in the COVID-19 Era - Ashish Kamat

Recorded Date: July 27, 2020

Ashish Kamat, MD, MBBS, joins Alicia Morgans, MD, MPH with an update on the effect of COVID-19 in Houston, Texas, and his practice at MD Anderson. Dr. Kamat shares an update on the BADAS trial investigating the use of BCG vaccination in combatting COVID-19 and touches on the ways in which social distancing measures have affected the exchange of knowledge between academics and physicians as conferences have gone virtual.

Biographies:

Ashish Kamat, MD, MBBS, President, International Bladder Cancer Group (IBCG), Professor of Urology & Cancer Research, MD Anderson Cancer Center, Houston, Texas

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.


Read the Full Video Transcript

Alicia Morgans: Hi, this is Alicia Morgans, GU medical oncologist, and Associate Professor of Medicine at Northwestern University in Chicago. I am so excited to have here with me today, a friend and colleague, Dr. Ashish Kamat, who is a tenured professor of Urology at the MD Anderson Cancer Center in Houston, Texas. Thank you so much for being here to speak today.

Ashish Kamat: It's always a pleasure to join you, Alicia.

Alicia Morgans: Wonderful. Well, Ashish, we've been dealing, and continue to deal, with COVID-19. And we wanted to, as you're here today, just reach out to people who are experiencing greater numbers of COVID-19 pressures right now. And Houston has certainly been a bit of a hot spot in the last number of weeks. So I just wanted to get your impression. How has this affected your every day urologic practice?

Ashish Kamat: That's a very interesting question that you ask, because when it first hit Texas like I'm sure the other places, our reaction at the Texas Medical Center was based on the limited information we had in the US and was based more on what was coming from our overseas colleagues in Italy, and of course, the East Coast in New York.

And everything sort of shut down at the medical center, except, of course, cancer cases. And within that, we prioritized, bladder cancer, for example, while the prostate cancer was relegated to, well, we could wait for a little bit — this is not rapidly fatal cancer for the most part. And based on what we learned in the handling of the situation by, not just MD Anderson, but the entire Texas Medical Center, I think they handled it really well.

I mean, the PPE distribution, the allocation of resources, was done well enough that today, we at the Texas Medical Center, actually have sufficient information, resources, resource allocations, and even experience that it really isn't affecting our patients as much now as it potentially could, if it wasn't in a large medical center like ours.

So yes, I mean, we still have bed crunches, but the bed crunches are more in theory, because we're still taking care of cancer patients. It's open now to any cancer diagnosis that we feel should not wait more than three, four weeks. Which is a lot of them, the majority of them, for example.

So everything's moving as we would like it to move when it comes to taking care of our oncologic cases, when it comes to surgery, radiation, medical oncology. But we keep an eye out on the number of cases. And the number of cases has dipped over the last four days, but we're still higher than we were, same time last month. So we're factoring all of that in and things are hopefully not going to reach that tipping point where we have to stop caring for our cancer patients again.

Alicia Morgans: 
Well, I think that's an excellent point that you raised because as we've continued to deal with COVID as compared to when we were initially facing it, and we saw it spiking in other places and had to prepare, we cannot really say to prostate cancer patients, for example, as you mentioned, hey, this'll be fine. If we just wait three to six months, we should be okay, we can use these temporizing measures and we'll monitor you closely. And we'll take care of this when COVID has gone because COVID is still here.
 
And I think that at this point, there's a general recognition that it is not going away in the United States for a long time. Until we have a vaccine, until we vaccinate everyone with that vaccine, and until we are able to control this virus. So what are you saying now to prostate cancer patients who maybe you're meeting in person, maybe you're still meeting via telehealth? What is your advice to new patients coming in and to patients who are considering screening for prostate cancer?

Ashish Kamat: Well, so that's the question that we wrestle with as well. Because as you mentioned, rightfully, it's not as though COVID's going to go away. People thought in March, hey, come summer when the weather is warmer, it's going to be a nuisance and not really a major issue. But we're now recognizing that even if the vaccine comes up as predicted by some now, in February, by the time it's available to the general public, it's probably going to be at least April or May. So COVID's a little bit of a chronic disease now. And we have to factor that in when it comes to recommendations we give to our patients.

So it's almost like you have to consider that a comorbidity that exists in the situation and then factor in the screening. So just as you would normally assess a patient and say, well, does he have X amount of healthy years left, is screening worth doing, you always have to factor in the exposure and the potential risks to a COVID situation. And then factor in whether a screening is necessary, whether you want to do a biopsy, is active surveillance more appropriate, or for some patients, is radiation more appropriate?

Because clearly, this was the debate that we had when we created these guidelines on an international basis and those published in European Urology some time ago. But the discussion was, well, if a patient comes every day for radiation therapy, how is that better than just biting the bullet and having surgery, for example. I mean, if it's up locally limited disease that's curable. And with a neoadjuvant chemo, for example, is the justification of sitting in the chair and getting chemo for a cystectomy worth the potential immunosuppressive risk, or should the patient just go straight to surgery and then decide on pathology?

So all of this was thought of then, with the idea that COVID would not be here for too long. But just as you said, it's more of sort of a chronic disease, so to speak. Hopefully not longterm chronic, but short term chronic. And we factor that in for every patient that we talk to. Is it worth it for this particular patient? If you're 84 years old and you normally would have done okay with chemo, now is it worth getting chemo or can we take you straight to cystectomy? For prostate cancer, obviously, same questions come in when we screen or make treatment recommendations.

Alicia Morgans: I think that's a great way to consider it because it is really ... There are general guidances that we can say, this cancer is clearly a problem now, COVID is not. You don't have an active COVID situation for you as an individual patient. So the risk of not treating the cancer, that we know of, is actually higher than the possibility that you could get COVID.

But there are others who may be at higher risk or who may make treatment decisions that are more ... Reduce their time and their interaction with the medical teams. Or move things to a different time when that's feasible and reasonable in terms of their disease because maybe COVID's not as big of an issue here right now, but we anticipate it could be in the future or vice versa.

So I appreciate that advice very much, that it's a constellation of the comorbidity, so to speak, of COVID-19, of SARS-CoV-2, and the patient's current cancer status and how those two compete in terms of what's best for the patient. So that's a wonderful way to frame it, and I appreciate that.

Another piece of this is clinical trials, and I know that you're very involved in academic research. You're actually involved in some clinical trials that are working to use strategies to treat non-muscle invasive bladder cancer, to potentially reduce infection with SARS-CoV-2 and potentially reduce the occurrence of COVID-19. Can you tell us a little bit about that?

Ashish Kamat: Sure, absolutely. So the study is BCG as Defense Against SARS-CoV-2. And the acronym is B-A-D-A-S, which again, we got when we did a patient focus group, initially, when we were designing the study. And they're like, oh, that's a great acronym, makes us feel so empowered. And what it is, is really using the knowledge that we've amassed over the years, that BCG is a very potent nonspecific stimulator of the immune response.

And there've been studies that have come out of Europe many years ago by Dr. Netea and his group using BCG to boost the immune response of patients who were then subsequently vaccinated against yellow fever, for example. And you do get this chromatin remodeling and memory of the immune system, et cetera, et cetera, not to go into too much detail. But the thought process there was, and is, to use BCG as a nonspecific stimulator of the immune response and to enhance the patient's own ability to ward off the Th-1 response to the virus.

The other benefit is that it does alter the Th-1, Th-2 balance, in the sense that we're not really expecting the immune stimulation to necessarily abrogate the incidence of BCG completely, maybe decrease it. But more importantly, switch that response to where the cytokine storm is actually much less in these patients. And again, that's based on data in other countries and other situations before SARS hit us and COVID-19 hit us this year.

So this trial in the US, as I said, is BCG as Defense Against SARS-Co-V2. It's currently restricted to healthcare workers or first responders — so EMS and firefighters and law enforcement. In Australia and in the Netherlands where it's supported by the Bill Gates Foundation, it's about 8,000, 10,000 individuals have been enrolled in the study.

And in countries like India ... And again, I've been talking to them and helping them with this as well. They've, in many parts, just rolled it out. And they're just going to monitor people and then do a cohort control, not a randomized control, but a cohort control for regions or localities where people are not exposed to BCG.

So that's what we're doing when it comes to actually using BCG as a potential defense against SARS-Co-V-2. Only until a definite or more focused vaccines available, because clearly that will trump a nonspecific vaccine.

Alicia Morgans: Still, I do think that it's really an incredible and thoughtful way as a urologist to work with the infectious disease folks, and to think a little bit outside of the bladder box, so to speak with, with the normal use of BCG. So I think that's great. And we really do look forward to seeing how that moves forward.

And I would also say that when we do have a vaccine available, it may or may not be available to everyone in all parts of the world, in the numbers that we would actually need to make a difference. And if this is perhaps a lower cost option that is more widely available, it can still help us in the long run depending on what we find. And of course, all those other circumstances regarding drug costs. So I commend you and I really do look forward to hearing how this will turn out.

Before we wrap up, one more question I wanted to ask you. You're very involved in medical education, you're an academician. You go to meetings, you certainly teach fellows. You were the former director of the Urologic Oncology Fellowship at MD Anderson.

Medical education, whether it's meetings, where we all get together and share our data, or whether it is education specifically for trainees, has been changed by COVID-19. Our travel is nonexistent at this point, and we aren't face to face with our colleagues and our trainees in the same way that we previously were. What are you doing in terms of forward-thinking and to make sure that we continue to share our knowledge, our data, and to have the best meetings and engagements that we can have? Because I know that you're a leader in this space, I'd love to hear your thoughts.

Ashish Kamat: So Alicia, when it comes to that, there are so many different ways to look at that. And I'm sure you ... Just as my perspective on this has changed over the last four months. When this first hit us in March, I mean, there were several meetings that you and I, I'm sure, would've bumped into, that were scheduled to happen that suddenly got canceled.

And the initial thing was, oh gosh, I wish I could meet my colleagues and I wish I could be there in person and do all that. But of course, we recognized the importance of going virtual. And then that whole virtual explosion took place, and then now many of us are virtual-ed out, right? And it's like too many Zoom meetings and too many didactics that are online.

I think though, that what's going to happen in our field, is the same thing that's happening in other fields when it comes to technology or energy or any other field, it's going to be a nice amalgamation of the best of both. We're all recognizing that we don't need so many in-person meetings that takes us away from our patients, our family, our home base. At the same time, we're also recognizing that doing everything virtual is not good when it comes to education.

But it's also not good when it comes to having that after-dinner conversation with several colleagues, where a lot of these ideas to come up with the clinical trial ... Or you and I share experiences, and I go, oh, wait, you're doing that. Maybe I should be doing that. And that's how we move the field forward.

So right now, our group and the International Bladder Cancer Group, the AUA, SUR, everybody clearly is focused on not letting our trainees and our colleagues across the world suffer by having all these virtual meetings. I think that will stay and that will persist, but we'll get back to doing in-person. Because the camaraderie ... I mean, I'm here with you on this Zoom call, but clearly meeting you is something that is at a different level. And we talk and we chat and we collaborate. So I think the best of both is what I'm looking forward to, but it's clearly not going to go back to the way it was when we were at meetings every other week. That was just too much, I think.

Alicia Morgans: Yeah, I would agree. And it will be interesting to see where everything settles out because ... For a large part, those in-person meetings, those impromptu conversations, those meetings in the hallways, those after-dinner conversations, they really do lead to scientific advances and certainly to spreading good practices clinically.

But it is a different world now, and we have to be able to do some of that virtually. And we have been and we'll continue to evolve, but maybe a mix of the two will ultimately be where we land. And I hope that we land, and I think that we'll land in a stronger place than we ever have been before.

So as we do wrap up, what would your final thoughts, guidance, recommendations be to the listeners regarding how practice has changed in this new era of COVID-19 now as a chronic problem that our patients are dealing with?

Ashish Kamat: I just want to make one comment. I want to give a shout out to all my colleagues, whether it's urology, internal medicine, whatever it is. I think what the medical community in the US and across the world has shown is just how resilient we are and how we truly care for the benefit of mankind. I mean, a lot of us were getting disillusioned by the way just healthcare is going in the US and other places and all the administration and overhead.

But COVID-19, in Italy and India, China, New York, and now Houston, I mean, everywhere really, has shown how physicians truly went into this profession because they care for others. I mean, we saw people flying from San Francisco to New York City in plane-full ... Doctors, just to help the patients and to help the nurses and vice versa. So I just ... No advice, I just want to tip my hat to my colleagues.

Alicia Morgans: That is an absolutely wonderful way to end this conversation. And I tip my hat as well. And I thank you also for your time and your guidance today. Thank you so much.

Ashish Kamat: Oh, it's always a pleasure chatting with you, Alicia. Take care.