Managing The COVID-19 Infection Rate and Continuing GU Cancer Treatment in the UK During the Ongoing Pandemic - Thomas Powles

August 3, 2020

Recorded Date: July 31, 2020

Director of London’s Barts Cancer Centre Thomas Powles, MBBS, MRCP, MD, joins Alicia Morgans, MD, MPH to discuss the impact of the ongoing COVID-19 pandemic on cancer care in the United Kingdom. Dr. Powles details how temporary protective measures set in place at the Centre in the early months of the pandemic, such as temperature checks and limited visitors, have now become permanent fixtures of patients’ hospital visits. While the hospital did not see a huge backlog of cancer treatments, it did see a 30 percent reduction in new cancer diagnoses due in part to the fact that patients were not coming in for routine visits or surgeries. With this number now increasing, Dr. Powles addresses the challenges that have arisen in determining the availability and frequency of COVID-19 testing, as well as how clinics will be reworked to maintain proper social distancing measures.


Thomas Powles, MBBS, MRCP, MD, Professor of Genitourinary Oncology, Lead for Solid Tumour Research at Barts Cancer Institute, Director of Barts Cancer Institute, London, United Kingdom

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, this is Alicia Morgans GU medical oncologist and associate professor of medicine at Northwestern University. I am so excited to have here with me today. Dr. Tom Powles who is a professor of GU oncology and the director of the Barts Cancer Center in London. Thank you so much for being here today.

Thomas Powles: Thanks for inviting me. Thank you.

Alicia Morgans: Wonderful. So, Tom, I wanted to talk with you to get an update on how you and the folks in London have been doing, given the ongoing COVID-19 pandemic, and really to get a sense from your perspective as the director of a cancer center, how things will continue to evolve and what steps you're taking to make sure that patients get the treatments that they need as they continue to experience this pandemic.

Thomas Powles: I get the impression that this is an ongoing problem. And I think that many of us felt that we perhaps by September, the problem would have gone away. I think that's what we all hoped. It doesn't appear to be the case. Certainly, what happened in London in the first three months between I would say the middle of March and the middle of May is we were in a healthcare environment that was quite unstable. I think the same happened in New York, and Madrid, and Northern Italy. And I think there was a lot of uncertainty at the beginning of that period about whether the numbers just continued to get worse and whether we actually were getting in control of things. And I think that created a huge amount of anxiety, and I think that that in turn resulted in a difficult discussion about what we would do and how we would do it.

The decision at our cancer center was to continue to treat cancer patients as much as we could. One of the things about cancer treatment is they last months and not days. So therefore you can't wake up one morning as a cancer center director and say, "We're just not treating the patients today." Because, at any one time, we've got about probably three or 4,000 patients on treatment of one description or another. And clearly one can't just stop. So even if you wanted you to stop new treatments, that will only be five... Well, Less than 5%, maybe one or 2% in the first week of treatment. So inevitably you have to keep going. And the question is, how do you keep going? And the way we did that was to essentially build an effective all around the cancer center. And the way we did that was we phoned the patients up before they came in and checked their symptoms, they'd be checked on the door, they'd had their temperature measured.

We were performing random testing on patients, we were performing testing on symptomatic patients. We weren't allowing friends or families into the cancer center. Carers could come with the patients, really difficult decisions to make, particularly in patients who were dying. But of course, shielding and isolation for the cancer patients, all really important issues. And what we discovered over a period of time in our random testing is actually, although the rate, the infection rates in the community were quite high in London, and I think the antibody data in London suggests that actually a significant proportion of the population got infected in the first wave.

We didn't see the patients getting systemic radiotherapy, chemotherapy or surgery. We didn't see those three groups of patients having a high percentage of positive tests. In fact, we now do random tests every week on 15 patients and they're invariably negative. I think we had one positive test about a month ago, which was a individual who previously tested positive, who hadn't yet cleared. So I think as it currently stands, the cancer center is safe. And actually, when we look back during this period we've treated 3000 patients given 9,000 treatments. And the mortality rate is really, really low especially with COVID. Now don't get me wrong — there are cancer patients who have come into harm's way, but they haven't actually been those patients who have currently been on treatment. And reassuringly some of the more recent data coming out of the US and some of these collaborative works, the UK, there was a lung cancer piece as well, it doesn't suggest actually the systemic therapy itself is associated with high mortality necessarily. I think having advanced cancer, advanced stage, I think these are risk factors. So where we are now is we're in a position where our infection rates in London is actually pretty low. So it's 0.2% of the population to one in 500 is testing positive. We still have the cancer patients who are isolating themselves to some degree as you would expect. And actually we're in a position where we're making hay when the sun shines in that we try to get through as much treatment as we can. We never really developed a big backlog, but there was about a 30% reduction in new diagnosis because patients weren't coming into hospital, GP surgeries, family doctor surgeries weren't working as well as we would like, obviously.

And of course, the diagnostics wasn't up and running properly. So we're now beginning to see those numbers increase. So two big challenges there. Challenge number one is when those numbers do increase, do we have the social distancing in place in the chemotherapy units, the rate of therapy units, outpatients to make sure that the patients are safe. We cannot suddenly pile all the patients in one Tuesday morning because that's going to create a big problem. So we're extending our opening hours. We're working more on weekends. We're doing video conferences with patients rather than face to face consultations, were not bringing friends and family in. The second important consideration for us, which I think is really relevant is are we testing? I've always felt in testing, it is at the heart of what we do. And so PPE and testing must go hand in hand. Of course, we go down on the face mask issue, which we feel strongly about.

We also make sure that patients continue to be screened. Patients and staff continue to be screened. And the testing for patients, we've not introduced testings for all patients on all the cycles, but we are randomly testing groups of patients. And essentially we're waiting for what we think is going to be the numbers increasing. And if you look in the media, you'll see the numbers are increasing in some parts of Europe slowly, I realized that at the moment the rates are 0.2% and low, but we can see them increasing a little bit. There are pockets in Spain, Catalonia, for example, I think Luxembourg has high numbers. You'll also see the areas of the UK Lester, for example, Oldham and the Manchester area are also showing an increase in some of their numbers. So one of the issues for us next is we're expecting to go back into a more protective period where we will do more testing.

We may end up testing each patient on each cycle. We also will be probably introducing strict entry criteria into the cancer center. And I think that if the numbers go back to where they were before, we will then step back on treatment again for a second time. So we've got a plan moving forward. The past looks like we got through a difficult time. If it happens again, we're going to go through and we're not going to stop as much as we did the first time. I think the diagnostics is going to be better because we've had time to prepare. I'm not positive about this, but I'm not enjoying anything about this pandemic, to be honest, but I think we're going to get better at it. And of course, we're waiting for vaccines.

Alicia Morgans: Well, I think it's phenomenal that you at Barts and London overall has such a low rate of positivity. That is really encouraging to the rest of us, that we can get there at some point and hopefully return to some semblance of normal, which it sounds like you are able to do at this point. One thing that's happened in the U.S. and I'm curious if this has happened in your cancer center, is that we have really limited patient's ability to have a carer come in with them or a carer to see them and be with them in the emergency department or in the hospital. And this varies of course, by geography of where you are in the United States, but many of the cancer centers in an effort to ensure social distancing are really not allowing these carers to come into the room.

And it's actually, it's incredibly traumatic for patients. And as you can imagine it's actually of course, stressful for the staff too, as they're trying to do all that they can for the patient and then forcing them to separate. So how are things in London, have you ever had to enact something like that? Are you using it now? And how are you overcoming that if you do have to use something like that?

Thomas Powles: First thing to say is that the UK has not done everything well. So we have the highest mortality rates in Europe. London was particularly hard hit. So we were not in a position to preach to anyone in the United States about what's happened. We've learned the hard way because we're very early in the process and our numbers are lower than numbers in many areas of the United States currently because we were hit very hard in February, March and you're now going through that same period. And I actually, when a review of what's happened takes place, which it will, and I hope the US and the UK work together in that process, we will discover that there were things that UK could have done differently. So I'm not for one second suggesting that we got everything right. And there were things that we've learned, and I hope that those things we've learned, we'll make sure it doesn't happen a second time. And protective material, protective equipment which wasn't great during the first time, I think is better now. And I think the US has been better at that throughout in my opinion, but that's an opinion. And we'll have to see what happens then, so not everything happening in London has just been great. And we need to learn from our mistakes, number one. Number two, the direct question you've asked, and I'm going to give you a very direct answer, and it's not a very compassionate answer. When I speak to my colleagues, the chemotherapy unit, for example, some up to 130 and 150 patients going through a day. If each one of those brings, or even if only 50% bring a friend or a family member that then becomes unmanageable. On top of that, for them, we haven't got the space to do it, number one. So we can't.

Number two, really important is that the friends and family members probably not going through... This sounds bad. The current data in Europe suggests that the population at less risk is taking the isolation process less seriously. I totally understand that if you're in your early thirties and you're fit and well, and you've got a young family, you've got to go out and work and do things. But the more elderly cancer populations are isolating themselves. So if you've got a woman or a man in their seventies or eighties on chemotherapy with prostate cancer, who's been isolating, next to a testicular cancer patient with their 35-year-old friend who was out playing football last week. It's just not going to work. And so you have to have sadly kind of a one size fits all rule because I'm sure you're the same.

We have people on the door and we're filtering people. Everyone wants to come in and everyone wants to see someone. And so you either say, "Okay, the hospital's open." And when we started, we have a shop in the hospital and the post office next door, the men from the post office, men and women from the post office would come and buy the newspapers from our shops. So that's the absolute extreme of where we are, but we're in a position now where we really do... I think we really do need to, as far as possible, keep fit full to the hospital as low as possible and keep people in the same category, the same group. Now, clearly there are patients who are dying on the ward, and that then becomes complicated. I don't know what it's been like in the United States, but if you read on social media, you'll see that actually patient's relatives were not allowed to see patients in the UK with COVID as they were dying.

And I understand why that was the case and it's perhaps with hindsight will be one of the most traumatic parts of this. And during the height of our lockdown, we weren't really having funerals with people either. So this whole process has been extremely challenging. I'm not suggesting for a second. I don't understand that challenge, but I also really, one of my biggest fear? And you'll read about the meat markets in the UK. There was one in Germany. You can get isolated outbreaks in quite confined areas that can fly very quickly. If that happened on a cancer ward, that would be a really bad thing. And so my number one priority is to prevent that happening to our cancer patients. If that means friends and family are unable to come to the hospital that is one of the prices that we will continue to pay.

And the last thing about that is we are not... I am very reluctant to release that now because, during the height of locked down four to six weeks ago, it was probably the safest time because everyone was locked down. Right now as the taps have been released people say, "If I can go to the pub, why cannot come and see my mother in hospital?" It's because you can go to the pub is why you can't come and see your mother in hospital. This is an extremely difficult conversation, which I don't necessarily have the right answers to. But the number one priority for us is to make sure we keep our cancer patients safe. And for that reason, we're limiting that.

Alicia Morgans: So that makes complete sense to me and is actually what's been happening in our hospital. It's interesting. So your hospital is a very cancer-focused hospital, which I think is helpful. We have a multidisciplinary hospital with general practitioners. I'm sure you have the same, but different wards within the hospital, or different parts of the hospital or different outpatient centers, which are also in the hospital buildings for us are relaxing some of those distancing policies and allowing some people to have their carers come in, which makes it very challenging for our oncology clinic, which is still not allowing carers. So interesting how these things evolve. And I feel very much the same way you do that protecting the patients as they go through this time, and are probably isolating themselves actually quite sufficiently because they know that they're going through chemotherapy or whatever traumatic surgical, or other treatment they're going through.

That's a different group of people than their relatives and good friends who may be able to go to the pub, or go out and play games on the weekends with friends. It's a different mindset. I appreciate that. It is encouraging to hear that other centers are doing that. And we're not the only cruel ones here in Chicago, and in the United States. I think it' a worldwide thing. And it's all for the safety of the people that we're trying to care for. So as we wrap things up, what message would you have to those who are listening, whether they're clinicians, whether they're patients, as they're trying to think through this ongoing stress that we're experiencing but still take care of patients or deal with themselves or loved ones who are dealing with cancer?

Thomas Powles: So in the UK, we have 160,000 cancer deaths annually, and that's a high number. And we have a fear that we are going to have more cancer deaths this year because the disruptive process of the pandemic has made it much more difficult to treat cancer patients. And our current message to cancer patients is we can treat you safely in a secure environment, and there is a high possibility or probability that your cancer treatment or your cancer risk is higher than your COVID risk. And for those reasons, if you have cancer-related symptoms, please come out and have those investigated because early diagnosis is the easiest part of the cure. And so that's the first message that we are currently saying to patients, "Please come out. We can treat you safely. And that's important." To my colleagues. I don't know what to say.

I think we've been through the first period of this and I think it's been emotionally exhausting. I think there is a degree of emotional fatigue and we just need some light at the end of this tunnel. And I think that's really important. I think taking time off is important. I think that working together as a team is important. I think a lot of the initial energy associated with making it work, I think some of that emotional energy is gone now. And now we need processes that work. We need hospitals that are functional. And I think we need to get into a new way of working, which is slightly different, but we have to make sure that we are also protecting the healthcare workers. Not just protecting them from the virus, but also protecting them from the emotional stress associated with the process, which I think will become more apparent as this goes on.

Alicia Morgans: Well, I think those are both great messages and I am sure that the people at Bart's are very fortunate to have such a leader who is thoughtful, and cautious and also compassionate as they're trying to make it through this. And we appreciate your words and your time today.

Thomas Powles: That's really sweet of you. It's lovely to see you again.