Alicia Morgans:  Hi, my name is Alicia Morgans and I'm an associate professor of medicine and a GU medical oncologist at Northwestern University. I'm so excited to have here with me today, a friend and colleague, Dr. Dan Spratt, who's an associate professor of radiation oncology at the University of Michigan. Thanks so much for being here to talk with me today, Dan.

 Dan Spratt:  Thanks so much for having me.

 Alicia Morgans:  Wonderful. So, Dan, we were just chatting a little bit about the effects of COVID on so many aspects of our lives. And I know you've thought a lot about the effects that COVID may have in terms of causing fear that could delay patient care, either because the patients are concerned about getting diagnosed or undergoing planned treatments, or because clinicians are really not sure how to juggle the risks and to make those decisions with their patients. So what are your thoughts really on COVID cancer care, specifically radiation treatments, as we're really in, at this point, the long haul, I think, dealing with COVID.

 Dan Spratt:  Yeah. So this is something on all of my patients' minds, I'm sure on your patients' minds, as well. It's this very complex juggle of many moving parts, the risk of a patient contracting COVID, and having morbidity or even dying of COVID versus the dangers in the delay of diagnosis or treatment of their cancer. And it's moving because it depends on what wave, what part of the pandemic you're in, and for a lot of the United States, and it's varied, where I'm at right now at the University of Michigan, the cases are extremely low. We sit at around 10 patients inside our hospital in inpatient versus at the peak, it was probably close to 400. So the risk of contracting COVID by coming into the hospital system, given all the precautions now that are standard, of wearing masks and social distancing, is extremely, extremely low.

So for radiation therapy, what happened initially during the peak of the pandemic is because there were so many patients, there was such a fear, but also a much greater risk of contracting COVID, we delayed patients of prostate radiation therapy with localized prostate cancer, and either if they were low enough risk, we would just observe them until we thought that the peak would pass, given that there was a very low chance of any harm from delaying the treatment. And if they had a higher risk of disease, the standard of care is to be given hormone therapy anyways, and so we would just extend that.

What is very relevant, I think, men with prostate cancer is that men are more likely to die of COVID. Patients with cancer are, as well, and older men, as well. And so I think sometimes there are men that have a lot of anxiety about entering the health system, but I think it's important for physicians to be able to have these conversations with them because, depending on their stage of the disease, it may not matter to delay their treatment, but especially as you get into more advanced disease, it probably could potentially affect them to not receive any therapy.

 Alicia Morgans:  So all of that makes sense. And we talk to our patients about really weighing the risks of cancer that we know that you have versus the possibility of getting COVID, and then the possibility that that COVID could be severe, but that's more of a theoretical for most patients at this time. How do you actually, as a clinician or as a patient, kind of make those calculations, because it's not something, I think, that's necessarily intuitive, especially when there's fear on both sides of that equation. So how do you do that?

 Dan Spratt:  Yeah, so this leads to something right around probably early March, my research team... and I'm really lucky to work with some incredible biostatisticians... we're always trying to figure out how do we help patients with prostate cancer. And it sort of switched from talking about the typical risk factors for our patients, to now you have coronavirus. And so we sort of pivoted our research to try to quantify exactly what you're talking about. And it's imperfect, but we've created, and it's an iterative model, there's a web app that's called oncovid.com, and what it basically is doing is exactly what you said, is it's trying to take... because every person's individual risk of having problems from COVID or their cancer from delaying it is different.

A 40-year-old man has an extremely, if they're otherwise healthy, limited risk of having a severe outcome from COVID. It's not zero, but it's small. If you had an 85-year-old with numerous comorbidities coming in for eight weeks of radiation into the hospital, maybe if they were to be given something that would be immunosuppressive, that could put them at great risk. And it all depends where you live, what's going on with the virus, everything, inserts all these moving parts, that it really no longer works to have a one size fits all.

And what happens, you as a medical oncologist, and you're always trying to personalize therapy by the subtype of prostate cancer, but what happened across the world during COVID, we essentially got rid of personalized medicine and most hospitals sort of said, okay, these patients keep treating, these patients hold treatment. These patients hold treatment a lot, and we sort of either did it by cancer type, by stage. We really didn't do a good way of really personalizing it as much as we would want to. And so now it's really the goal of this to quantify it in a quantitative and integrated way. And it does provide reassurance to patients that coming in for treatment typically, especially with how low the infection risk is right now, there's really no benefit to delaying treatment in terms of the risk of COVID because, as you said, we're kind of in the long haul, it appears right now, unless something else changes.

And so it kind of puts their minds at ease, but at the same time, especially for other cancers where we don't have therapies like ADT or hormone therapy that sometimes can act as a good suppressive therapy... head and neck cancer is something that these patients really can't delay because they have a much greater risk of dying of their cancer with treatment delay. So it's helped, I think, a lot our patients, when I go over it with them, if they have anxiety, to really quantify that often it's sub 1%, sometimes sub a 10th of a percent of them coming in, and that maybe no different than them going to the grocery store.

 Alicia Morgans:  And that's so helpful, I think, to kind of view those numbers more as quantities or actually numbers than just sort of this amorphous risk. So I'm glad that that's been so helpful and I'm glad that it's so reassuring to folks where you are in Michigan, but let's think back, back to the summertime, maybe right after Memorial Day. Rates were actually pretty high in places like Phoenix and parts of Florida, for example. So if you were taking care of a person in those places, can you just walk us through what do you enter in the app, and what might the output look like so that when things are kind of heating up in terms of COVID what might that output look like?

 Dan Spratt:  Sure. So I think some of the big variables that go in is a patient's age. The older you are, unfortunately, appears to be a major risk factor for having problems with COVID. Comorbidities, so certain comorbidities appear to be consistently linked to a higher risk of having problems with coronavirus. Where you live. So we actually have linked the app to the Johns Hopkins COVID tracker, where they have county-level estimates, kind of pretty accurate, updated constantly. So you put in your state, your county to find out the trends and what's going on there of your risk because as you said, you can have different waves. And so although being in Florida or in Phoenix could be definitely a problem more recently. And then you put in the type of cancer you have. So in this case, if it's prostate cancer, if you have prostate cancer, up put the stage of the cancer, and you put the types of treatments that your doc's planning.

So are you planning to get chemotherapy? Are you planning to get surgery, radiation therapy? How many appointments? And so through all of that, it sort of estimates kind of the benefits and harms of delaying treatment, so you can kind of quantify that. Often it's on the order of days, benefit and harm. And if it's something that small, I always error on the side if it's a very, very small difference, I say, you never know what's going to happen three months from now. It could be better. It could be worse, but we know right now it's a low risk or a high risk and you kind of go with what you know right now.

 Alicia Morgans:  I think that's great. And we'll make sure that we have some information about the app along with this story so that that people can really hit that link and get to explore it more. The final question I have is that we are continuing to evolve in our understanding of how different co-morbidities may affect patients in terms of their risk and lots of different variables. Is this app something that you're anticipating will evolve over time, as we continue to learn more about the effects of these different aspects of a clinical situation and how that might affect a patient's outcome in terms of COVID?

 Dan Spratt:  Absolutely. The credit really goes to a brilliant woman. Her name's Holly Hartman, who's a Ph.D. biostatistician, and I think we're already on the second or third iteration of it. And we're all learning constantly. So as new publications come out and new data comes out, it gets continually refined to exactly your point. So we hope to be able to continue to support it, continue to update it, and hopefully cases we can keep low so our patients with cancer can continue to get their treatment.

 Alicia Morgans:  That's fantastic. Well, I sincerely appreciate that you and your team have really worked so hard to help people take this fear that can drive us in a lot of different directions, not always the most rational direction, no matter how thoughtful we are, and put a number around it, which helps us to at least start to put things in a little bit of a perspective where we can make a logical and rational decision about the cancer we know and the COVID that's possible. So I really appreciate your help and your awesome work. As always, thank you for your time, Dr. Spratt.

 Dan Spratt:  Thank you so much for having me.