More Data Needed to Guide Cancer Care Decisions Amid COVID-19 Crisis

Petros Grivas, MD, PhD

In the absence of definitive data regarding the risk of COVID-19 to patients with cancer and information to guide daily treatment decisions in the interim, Petros Grivas, MD, recommended converting the majority of patient visits to telehealth appointments and basing a patient’s need for treatment on their medical comorbidities, performance status, and cancer risk.

“Our goal is to keep patients away from the cancer center as much as possible, but if someone has an actively progressing cancer and needs treatment, we cannot ignore that,” said Grivas, a physician with Seattle Cancer Care Alliance. “We have to carefully balance the benefits and risks of each therapeutic intervention as well as the need to visit the hospital or the cancer center.”

In an interview with OncLive, Grivas, who is also an associate professor in the Department of Medicine, Division of Oncology, and clinical director of the Genitourinary Cancers Program, University of Washington School of Medicine; and associate member, Clinical Research Division, Fred Hutchinson Cancer Center, discussed the repercussions of the COVID-19 pandemic on oncology practice patterns, the importance of contributing to the COVID-19 and Cancer Consortium Registry, and maintaining open channels of communication during the pandemic.

OncLive: How has the COVID-19 outbreak impacted clinical practice?

Grivas: At this point, our first priority is to carefully evaluate our schedules in the ambulatory and outpatient setting to see which patients do not need to come to the cancer center. Day-to-day announcements and updates are being followed closely. Each provider has to go through their list of patients, on a daily basis, and decide whether they need to come in. For example, if the patient needs to receive treatment, they need to come in and get treatment, [and we need to take every] precaution. However, there may be patients who can [get by] with a telehealth visit, such as those who would come in for long-term follow-up from treatment. We’re converting all of those visits to telehealth or phone calls, depending on credentialing.

[Whether we will continue] chemotherapy or immunotherapy, which are very commonly used in the treatment of patients with genitourinary cancers, will require an individualized discussion with the patient. I don't believe we have [adequate] data to drive our decision. To my knowledge, there are only data for about 18 patients [which showed that] patients with cancer have worse outcomes from COVID-19; however, it is a very small sample size, and no active prospective comparator or control arm [was in place]. Some of the patients had remote history of cancer, so it's very difficult to discern the signals [from this data set] to make decisions.

To address that unmet need, we're in the active phase of developing a cancer registry. It’s very important that we alert our colleagues all over the country to this effort. The registry is being developed in collaboration with [our colleagues Jeremy L. Warner, MD, MS, and Brian I. Rini, MD, from] Vanderbilt University. We, at the University of Washington, are also actively involved. It’s important to engage as many colleagues as possible around the country to enter data in this live database to help us gather information to guide treatment decisions. [With this information], we can determine how best to treat these patients, what the risk factors are, etc. We’re trying to close the [knowledge] gap by creating data that will help guide our day-to-day decisions.

Is telehealth being used as the primary means of patient and physician interaction? What are the benefits and challenges of such an approach?

Telehealth is not a completely new idea; it has been around in pilot phases in a few institutions and organizations in the past few months to years. Many restrictions have been noted with telehealth and [people are still trying to determine] how it can be implemented in an optimal way. In the context of this crisis, we have to [use telehealth as] an opportunity to take care of patients. We have to reconsider and recalibrate how we implement patient care. Patients who do not need to come into the cancer center for specialty treatment can potentially be seen through a telehealth visit. That being said, the physical exam [of that visit] won’t be optimal. I’m sure we’ll get better at [performing physical exams through telehealth]. By using a camera, we can still perform a basic physical exam and see the findings. [For example, we can still] examine their skin. Patients may even be able to take their vital signs at home; they can tell us what the number is.

At the end of the day, it’s a careful risk-benefit situation. You may miss some elements of a physical exam [by using a telehealth visit], which, of course, is not optimal. However, the benefits of keeping patients at home, if they don't need to come in, outweighs [these challenges given the circumstances]. A public announcement was made [recently] that Medicare is going to cover telehealth; this shows that in times of crisis, problems that we’ve had for years with red tape can be taken down instantly. We have to rethink the way we can utilize technology to care for our patients, even once we get through [the pandemic], which will hopefully leave us stronger in the end.

Are you modifying treatment schedules or regimens for patients?

It’s very difficult because we don’t have any data, so we try to make educated and informed decisions on a case-by-case basis. That’s an important point to make, because it's hard to develop guidelines and criteria to cover every possible scenario. Very good attempts have been made from the American College of Surgeons regarding which surgeries are elective and which are not. Each institution is trying to define their own criteria. For example, some patients with high-risk urothelial cancer need surgery as soon as possible. You can’t wait forever because of the risk of metastasis, [which can lead to] dismal outcomes.

In prostate cancer, how should we stratify patients with low-, intermediate-, and high-risk disease [in terms of their treatment] timeline? How do we balance [their need for treatment] with the [risk of] COVID-19 [on top of] the need to create capacity for beds in the intensive care unit (ICU)? We have to carefully balance those [needs] and have a detailed discussion with patients on a case-by-case basis. It’s very important for patients to communicate with their providers; they need to ask specific questions and have a dialogue. It's very important not to neglect the cancer risk in some patients. For something that is medically urgent, [we’ll proceed] with great precaution. [On the other hand], completely elective procedures can wait.

Systemic therapy is another big area of discussion. People are asking me whether I still give neoadjuvant chemotherapy for cisplatin-eligible patients with bladder cancer; that's another area of big debate. On one side, you have the risk of immunosuppression with chemotherapy. On the other hand, we know these patients have better [oncologic] and psychological outcomes [with neoadjuvant chemotherapy].

The other problem is the [timing] of surgery. The urologist may recommend that chemotherapy be administered if it can be done so safely to buy them time if they can’t get to the emergency room. Again, it’s a case-by-case basis. If someone is fit for chemotherapy, extreme precautions should be exercised. You should also consider their medical comorbidities, performance status, and cancer risk. The list goes on and on, but we cannot cover every scenario.

The use of immunotherapy is another big question. Do you keep giving checkpoint inhibitors every 3 weeks or every 2 weeks? Do you increase the interval? Nobody knows the answer to that. If I have a patient who has completed 2 years of checkpoint inhibition and has a near complete response, I may consider holding off on further therapy in the context of COVID-19, so patients don’t have to visit the cancer center.

Are we in contact with physicians overseas on how to best contain the virus and reduce the spread to those at greatest risk?

I'm so amazed to see the open [channels] of communication in the past few weeks with colleagues from all over the world. Social media, as well as forums like this, have helped a lot with that [dissemination of information]. We have been in continuous contact regarding possible practices and we’ve been sharing anecdotes of patients who had good outcomes with X approach versus Y approach. It’s important that we keep these global channels of communication open, and try to create registries like the one I mentioned earlier; it is very important to get that up and running as soon as possible.

A huge effort is also being made to expedite clinical trials. Institutional reviews boards are very open to expediting those efforts. The first randomized trial has already been published in the New England Journal of Medicine a couple of days ago; unfortunately, this was a negative trial with antiviral medications. We need to keep trying. We need to keep designing trials, [collecting data] with registries, and communicating with each other as quickly as we can to disseminate information.

Could tocilizumab (Actemra) and hydroxychloroquine (Plaquenil) be repurposed for the treatment of patients with COVID-19?

Anecdotes and case reports are being discussed here and there. An ongoing trial is examining the use of prophylactic hydroxychloroquine in people who were exposed to patients with COVID-19. The trial is up and running. At this point in time, we don't have concrete evidence [that demonstrate the utility of these drugs as treatment or prophylaxis]. These are all anecdotes, which are important; however, they need to lead to clinical trials that can answer these questions systematically. If anything, we should try to capture all these anecdotes, which is where the registry becomes important. Every time we see a case of a patient who is infused with hydroxychloroquine, tocilizumab, or something else, we should capture that [information] so we can learn as much as we can in a systemic way.

Is there anything else that you would like to emphasize?

The take-home message is that we need more data; that’s why registered trials are important. In the inpatient setting, we're trying to increase capacity for ICU beds and have a maximum capacity should more COVID-19 cases come in. Every patient should discuss with their oncologist, urologist, or other provider what the best scenario is for their particular case, because one size may not fit all. Some cancer centers have the opportunity to screen patients at the door. [At our institution], everyone who walks in the main entrance of the center is screened for symptoms by someone who's asking them questions. If they have symptoms, then they are being triaged to see if they meet the criteria for swab testing. We don’t have tests for everyone. At this point in time, [we have to] screen and select who is going to be tested until we obtain more tests. It’s a good practice to at least screen people with questions and then triage them accordingly. Each institution has to create their own algorithms and procedures in real time.

Things are changing day by day. Another important message is to stay informed. Depending on the capacity of your healthcare system, you can have a location for patients with COVID-19 to go and identify some other hospitals or cancer centers that don’t have any COVID-19 cases to triage accordingly, depending on the COVID-19 status. This is a systematic approach that institutions take. It’s important for institutions to use their resources and communicate [appropriate] information with both providers and their patients.