Keeping Up With COVID-19: Adaptability Is the Strongest Weapon in the Arsenal

Balazs Halmos, MD, MS

Just as the situation with COVID-19 continues to rapidly evolve, the oncology community must actively adapt how they approach the treatment of their patients based on the information available, according to Balazs Halmos, MD, MS.

“We've implemented a lot of changes [with regard to how we’re caring for patients]. Institutions that may need to make similar changes later on really need to understand that the changes that they make one day, may change the next day,” said Halmos. “This is a rapidly-evolving epidemic, and we all need to be highly flexible. We need to adapt to address day-to-day needs in terms of staffing, resource utilization, and [treatment].”

In an interview with OncLive, Halmos, director of the Multidisciplinary Thoracic Oncology Program and director of the Section of Thoracic Medical Oncology for Montefiore Health Systems, and first director of Clinical Cancer Genetics and professor of clinical medicine at Albert Einstein College of Medicine, provided insight on preventive measures put in place at his institution to reduce the risk of exposure to the virus, day-to-day challenges faced in practice, how he is approaching treatment modifications for his patients, and how he is staying connected with the broader community to share information and experiences.

OncLive: What is known about COVID-19 thus far?

Halmos: We certainly know a lot more about COVID-19 than we expected to know; this is a coronavirus that appears to have jumped species and started an epidemic of significant proportions in China. The virus has since spread throughout the world. Currently, it’s at its height in Europe as well as here, in the United States. Especially in certain parts of the country, such as where I work in New York City, the numbers are staggering.

This pandemic rushed us to reconsider our practices, especially with regard to how to care for patients with COVID-19 who come to our hospitals in very large numbers, but also our patients with cancer who continue to need our attention and still require treatment for their disease. COVID-19 is a respiratory pathogen that seems to be incredibly contagious. As such, it provokes a very specific concern, not just with regard to overwhelming the healthcare system, but [the fear] of potential contamination of our patients who come into the clinic for care. Multiple elements make it very complicated for our patients to receive the appropriate care, but we all need to come to work and figure out ways to be able provide that care to our patients.

How has your institution responded to the pandemic?

The Montefiore healthcare system is a fairly large healthcare system, where we see patients with cancer at multiple performance sites. One of the first things that we decided to do was move all our patients with cancer into 1 freestanding facility. We can provide very safe access to the facility by screening every person who enters the building, providing masks to each and every patient as they come in, and ensuring that our providers have appropriate personal protective equipment through the patient care experience. We made that decision really early on and we're very happy that we did. That way, we can minimize the potential for infection with the virus in our patients with cancer who are very vulnerable.

It has been reported that infection with the virus is leading to severe respiratory complications in some patients. Working in lung cancer, are you finding it difficult to differentiate between symptoms associated with treatment in this space versus those associated with the virus?

Indeed, it can be a major challenge. We know that pulmonary complications can be an issue with many of the agents [in this space]; for example, checkpoint inhibitors and pneumonitis. However, targeted agents can also lead to lung complications. On top of that, many of our patients receive radiation, which leads to a number of changes on a patient's CT scan and can also lead to pneumonitis. All those things can mimic the changes we can see with a COVID-19 infection.

Of course, if we had rapid testing for COVID-19, this challenge would be greatly diminished because we could very quickly screen patients and know whether they are positive or negative. We’re making major advances in this regard. The epidemic arrived in New York City a few weeks ago and the testing took 3 to 5 days [to yield results]. Now, we have in-house testing; this is a polymerase chain reaction-based test, so in a way, it's not a very complicated test for a molecular lab to run. Our molecular pathologists recruited very eager, smart medical students who work 24 hours a day. As such, for our in-house patients where rapid testing is needed, we can really turn [results] around in a couple of hours; that's key. Without the availability of rapid testing, how do we make those [treatment] decisions? I'm super happy to be able to offer that to our patients and providers. However, yes, it does continue to be a challenge and one that we need to be able to overcome to be able to offer the right treatment to our patients.

In the shift to telemedicine, are you experiencing any challenges?

We had to implement so many different practices [in response to this pandemic]. Ultimately, we want to prevent patients from getting infected, protect them throughout their care, and enable them to receive the right care. Starting with the prevention, if we can avoid patients having to come into the clinic, and they can receive visits through their home environment or visits can just be deferred, that's probably the safest way to manage them. For example, with regard to patients who are supposed to come in for every-6-month visits, those visits can be delayed. If patients just had a CT scan, and the scan results are negative, we can discuss them very well over the phone.

Of course, many patients will still need to come in for appropriate care, and that's where we need to [do our best to] protect them through their experience. By bringing them into safe facilities, providing the type of safe environment that I mentioned earlier, [we can do that]. Thanks to our colleagues in China and Italy, we were able to learn from their experience and thus, were able to introduce that [safe environment] early on. Providing that to our patients is very important, and then, through the care experience, we might need to make some modifications for the treatments to be safer.

You mentioned lung complications being complex in terms of figuring out whether they are from COVID-19 or from treatment. However, in reality, even if there is no diagnostic dilemma, if a patient has a life-threatening infection in the middle of aggressive chemotherapy, when their immune system is suppressed, their outcome will be a lot worse than it might be otherwise. As such, wherever possible, we may need to diminish the aggressiveness of chemotherapy, delay some treatments, limit the number of required visits, opt for oral agents instead of intravenous agents, and potentially offer other choices, such as deferring the start of treatment for certain patients. With regard to checkpoint inhibition, however, some of these agents can be given at a lighter schedule. Maybe we don’t give them every 2 weeks and give them every 4 weeks instead; in that way, we can limit the experience and the potential exposure for our patients that way.

Have you or your colleagues treated a patient with COVID-19? How did you approach care?

Many patients are undergoing treatment, and for each and every one of them, we're looking at ways to minimize their potential exposure. Unfortunately, we have had patients with COVID-19, as well. We've seen some fatal outcomes. However, we recently had a discharge that was very surprising; this was a patient on chemotherapy where I thought, “Oh my goodness. This is lovely, but very frail patient who might not pull through.” But she did, so there's definitely hope. We need to provide the right treatment and right support to our patients.

Even with COVID-19, our facilities are completely being revamped; new intensive care units are being opened up left and right. I'm very impressed honestly, not just with how institutions have responded to this pandemic in the city, but just healthcare workers in general who are giving up their extra time, volunteering, and are willing to be redeployed to new units. This is definitely a time that unifies the healthcare worker environment and we have to pay a lot of kudos to our nursing staff and supporting staff who are willing to do that. We fortunately have some physician champions who are pulling the extra burden, as well.

Twitter has also become a resource that is bringing the medical community together during this time. How are you utilizing that platform to obtain information and share experiences?

It's incredible how medical education became a whirlwind experience. In a heartbeat, you learn about major developments. Now, with COVID-19, that has gotten even more amplified. The content is just amazing. We all quickly steal ideas and information [from one another] and share it with our colleagues in-house. Indeed, Twitter has become an incredible resource that I greatly appreciate being able to use. However, it's not just Twitter, it's your team, OncLive, as well as PER, and other educational entities who are doing a great job, as well. Keep up the good work!

What would you say is the biggest challenge that you’re facing in practice right now?

We mentioned the prevention and protection aspects of all this, but we didn't talk about the enabling part. Determining how to appropriately manage patient care is very challenging. In this whirlwind situation, so many things are shifting, and [sometimes] you don't know how to provide the right care. It's one thing to prevent your patients from getting the infection and protecting them through their care, but can you actually provide the right care [at this time]? This is very frustrating for us physicians who are used to the idea that “Yes, we can provide a standard of care.” However, now we are finding that we have to compromise to a point, as well.

Many times, we are unable to provide a standard of care. Is there a reasonable compromise that you can be comfortable with, as a clinician that in the middle of this epidemic? You’re offering treatment choices to patients that are not crazy, but do not always provide the ability to manage the disease to the best of your abilities in the middle of this situation. For example, how do you provide cancer care when there's no surgery that's being performed? How do you provide cancer care where you cannot get diagnostic procedures done, such as a bronchoscopy? This used to be a bread-and-butter, everyday [procedure] for a pulmonary oncologist to be able to pursue. Very basic elements of care are suddenly missing completely. Can you temporize the situation? Can you offer some treatment so that the surgery can be deferred, so that reasonable safety could still be offered? Many times, we just don't know.

We're coming up with some makeshift decisions and this is again, where I have to say that social media is fantastic, in that we’re learning from others with regard to how they [approached] a situation. Guidelines are very quickly being released as to how institution A versus institution B dealt with [specific issues] and that provides us with a level of comfort that we’re not alone in this. We're all struggling, but we're making reasonable decisions, the best decisions [we can make] under the circumstances.

The second aspect is the emotional element. We’re anxious, too, as healthcare workers in this environment. We can be exposed. We can get very sick. We've lost nurses and physicians in New York over the past couple of weeks. But how about the patients dealing with a life-threatening illness and then facing this terrible epidemic? They might be admitted to the hospital, where they cannot be visited by their family members. Key decisions need to be made with them, such as hospice transition, and that level of comfort that their loved ones can be with them is just not there. We really all need to go the extra mile, and we are learning day by day how to do that in a practical way to still provide the care, the compassion, and the attention that patients need from us.

Are there any ongoing research efforts that you wanted to highlight?

The scientific machine has started, but in the United States and worldwide. Although there have been some delays in terms of getting things going in the United States, by now, everyone's attention is there. I'm very impressed by how quickly clinical research got going [for this]. In our institution, as well as I'm sure in many others now, clinical studies are examining antiviral agents as well as novel agents to block the cytokine storm that's associated with the virus.

Other clinical trials are taking the serum from patients who recovered from the viral infection and basically treating critically ill patients with that. Hopefully, vaccine studies will be here very soon, as well. I'm very amazed by the speed of science and hopefully that will yield a lot of dividends. But that’s not going to happen today, nor tomorrow, nor within the next couple of months. As such, within that period of time, we need to do our absolute best with the resources and tools that we have available to keep our patients as safe and as healthy as possible.

What is your advice to your colleagues?

This is a very stressful time and one thing to remember is that we need to learn to be super flexible. You need to adapt to the changes [that come with this pandemic] very quickly. Second of all, this is truly a unifying moment for us working in healthcare. We need to cherish it in a way and embrace that. We need to learn from our colleagues and work closely with them. This is not the time for competition; this is a time for working together. I'm starting to see that this [collaboration] is happening, and I just want to encourage all my colleagues to continue to put their best effort forward as a team to pull through this incredibly challenging time.