From the Frontlines: Choueiri Talks Shift in GU Cancer Care in Wake of COVID-19

Toni K. Choueiri, MD

Being a medical oncologist during the global pandemic of novel coronavirus 2019 (COVID-19) requires an all-hands-on-deck approach, and the ability to make daily, and sometimes hourly, adjustments as the virus continues to impact the healthcare system, explained Toni K. Choueiri, MD.

“This is an unprecedented crisis. This is [something that maybe happens] once in 100 years; we can be as ready as we want [for COVID-19],” said Choueiri, director of the Lank Center for Genitourinary Oncology at Dana-Farber Cancer Institute and Jerome and Nancy Kohlberg Professor at Harvard Medical School. “We are trying our best here. Again, it is an all-hands-on-deck [approach].”

Adjustments he has had to make thus far for his patients across genitourinary (GU) cancers include postponing some long-term follow-up—while staying within recommended schedules— some altered treatment decisions, and screening for COVID-19 symptoms. Moreover, he has been utilizing telemedicine and conducting virtual appointments for patients who perhaps are not on systemic therapy or live out of state.

In an interview with OncLive*, Choueiri, who is also the leader of the Kidney Cancer Program at Dana-Farber/Harvard Cancer Center, highlighted the changes he has observed in clinical practice amidst the COVID-19 pandemic and the unified approach being taken at Dana-Farber Cancer Institute.

OncLive: A lot has occurred in the United States over the last couple of weeks. How has your practice evolved in the last several weeks with regard to COVID-19? What are you noticing?

Choueiri: What I want to emphasize is that the situation is very fluid, and it does change by the day, or even by the hour. Therefore, we immediately went into a system where still, as of today*, patients can still come in [to clinic]; however, for many situations, we are transitioning to phone calls, or virtual visits.

Who are those patients in whom we are delaying some follow-up, or we're transitioning to phone calls? These are the patient who are usually not on systemic therapy, or have been on systemic therapy for a long time. These are patients for whom the follow-up, by guidelines, is 6 to 12 months; they could be delayed to 9 months. These are patients who sometimes cannot come in for whatever reason; they cannot fly, and perhaps they're out of state.

The situation is fluid. I can tell you what's happening in our unit in GU oncology. Every provider has a list of all the patients over the next month or 2 and we go through it in a thorough manner one appointment at a time. This is a massive effort, everyone has hands on deck. So far, it is an impressive show of leadership from our leaders at Dana-Farber Cancer Institute who are working 18 hours per day—nonstop. In a few days, 3000 [staff members from our institute] have transitioned to working from home with access. We are adjusting in real-time.

What preventive measures are you taking in your practice for your patients with cancer during this time?

Social distancing is one that applies to all of our population—whether patients are low or high risk. It's very important to practice it; we understand it is hard sometimes. We started by screening patients who are coming in but have been in areas that had [several cases of] COVID-19. Now, [as of March 20, 2020] we're [also] screening for symptoms that can happen with COVID-19, such as fever, shortness of breath, and cough, among others.

How will this virus impact patients with cancer?

Patients with cancer are at higher risk for complications from COVID-19. We can cannot claim to be experts in something that has been [around for a] couple of months, [but COVID-19] also didn't start here. Therefore, we also don't have first-hand experience. But, we know that patients with cancer are at high risk because they may be receiving some systemic treatment; this includes things such as steroids and chemotherapy. They're coming [to a medical institution where there is] a potential concentration of other patients, so they're at risk. Now does that apply to a larger blanket to patients? For example, let's say [a patient with] stage I cancer [had their cancer] removed surgically 4 years ago—are they at higher risk?

Other things come into mind: Are they smokers? Do they have comorbidities? It's complex to say. Perhaps it's the whole thing that comes with cancer. We are trying our best to take everything case by case.

Has there been a hesitancy with using immunotherapy as may further compromise a patient's immune system and put them at higher risk for COVID-19?

I don't think we know at all [...] but you have to think about it from a different perspective. Do we know if giving immune checkpoint blockade block or change something at the level of the nasal epithelium or the lung epithelium that make us more susceptible to have the virus? We have no idea, but what we know is that patients on immune checkpoint blockers are at risk for immune-related adverse events, and when you use 2 [immunotherapies] at the same time, the risk is higher. If someone needs to be on steroids because they develop colitis, hepatitis, or pneumonitis, we know that it is not a short course of steroids. Usually these steroids [are given] over 1 month or more, and is then tapered very slowly. Therefore, their immune system is at risk in this situation.

We have to think not just about giving immunotherapy but what comes [along with] immunotherapy, such as steroids. It is the same thing for chemotherapy. If you give someone chemotherapy, and they have an adverse event (AE), such as nonstop nausea or vomiting, and they need to go to the hospital to be treated with intravenous fluids—then they are going to be in contact with other people no matter what. You have to think about that what happens down the road and that trickling effect.

You have been discussing a lot of trends and various reports on Twitter related to the virus.

What has surprised you the most so far, as we learn more about this virus?

I definitely haven't claimed to be an COVID-19 expert or even [an expert in] infectious disease; I'm a medical oncologist. I get my numbers from the Center for Disease Control or from the Johns Hopkins University website. [According to recent reports, China has had 0 [new local] cases.

South Korea adopted very rapid testing processes. In those patients who carry the virus but are asymptomatic, they can be isolated or practice social distancing. [South Korea] has done that, and their COVID-19 numbers went down. Unfortunately, we do not understand how in Italy, the numbers are very high. The mortality is really sobering. We do have a lot of friends and a lot of close colleagues in the GU oncology community in northern Italy, which has been hit very hard in areas in Milan and the Lombardy region. We send our virtual hugs again—social distancing—and we support them. Doctors that are retired have been called, even outside their specialty, to pitch in.

Is there anything else that you would like to add in terms of treatment decisions you may now be changing for your patients with cancer?

There are treatments that may not be needed, treatments that haven’t been proven [to be lifesaving], and [we may need to] decrease the rate of follow-up if it's not needed. These are all very important things, especially in a situation where the level of evidence is very low. On the other hand, I would say even in, for example, patients with metastatic testicular cancer, you have to stay on track; you can't play around here and give 1 drug and not give the others, or skip a cycle here and there. You cannot because you don't want to lose the cure.

In hormone-sensitive prostate cancer, where you have a choice between androgen receptor (AR)—directed therapy or docetaxel; with docetaxel, [the patient has to come to the clinic]. With all of the potential AEs from chemotherapy, I would clearly go with AR-directed therapy where [the treatment can be] can be given from home, and the AEs are low.

We're trying to adjust case by case. I want to throw a shout out to my colleagues and everyone here at Dana-Farber Cancer Institute in the Division of Genitourinary Oncology; everyone has stepped up and are having an all-hands-on-deck approach. We're all working 24/7 and are trying as much as possible to have a unified approach and be in the best shape or form for the interest of our patients.

*Editor’s Note: This interview with Dr. Choueiri took place March 20, 2020.