Oncologists Collaborate to Navigate the COVID-19 Storm

Gail J. Roboz, MD

As the COVID-19 pandemic beats down on major cities like New York, oncologists across the United States are either bracing themselves for what will hopefully be a peak in cases or desperately preparing for when the storm will hit their own health systems.

“For us [in New York], it's all about the surge [of cases] that we're experiencing and what the peak of that surge will look like. Is it 2 weeks? Is it 1 month?” said Patrick I. Borgen, MD, chairman of surgery at Maimonides Medical Center in a recent webinar on the virus hosted by Physicians’ Education Resource^®.

Borgen was joined by a panel of experts including Jame Abraham, MD, breast cancer oncologist, chairman of the Department of Hematology & Medical Oncology at Cleveland Clinic, and professor of medicine at Cleveland Clinic Lerner College of Medicine; Leora Horn, MD, MS, assistant professor and clinical director of the Thoracic Oncology Program at Vanderbilt-Ingram Cancer Center; and Gail J. Roboz, MD, a professor of medicine and director of the Clinical and Translational Leukemia Program at the Weill Medical College of Cornell University and the NewYork-Presbyterian Hospital.

“Almost everything we have been told thus far has been wrong; however, we are still optimistic that we will see a peak sometime in mid-to-late-April,” said Borgen. “[In the meantime], we are fighting [an ongoing] battle of not having enough ventilators.”

The number of confirmed cases in New York state continues to rise, with the New York State Department of Health reporting the statewide total to be 122,031 cases as of April 5, 2020; more than half these cases, 67,551, have been reported in New York City alone.¹ Healthcare systems across the state are struggling to accommodate the growing case count.

In an effort to address this need, Governor Andrew M. Cuomo announced that 1000 ventilators have been donated to the state by the Joseph and Clara Tsai Foundation; the ventilators arrived in JFK Airport on April 5, 2020.² Additionally, 1 million surgical masks, 1 million KN95 masks, and more than 100,000 pairs of goggles have also been donated.

Additionally, a Navy ship referred to as the Comfort was also recently sent to New York as a way to relieve pressure on city hospitals. Despite the assurance from President Trump that the ship would play a “critical role” in the fight against the virus in the city, the ship has been docked at Pier 90 in Manhattan since its arrival on March 30, 2020. Due to the strict rules that are in place regarding patient admittance, only about 20 patients are on board the ship, as of April 3, 2020, according to The New York Times.³

“It is like nothing like I have ever seen in 25 years, to see this magnificent empty city of New York and this tremendous healthcare crisis,” said Borgen. “This crisis came out of nowhere, and it’s crashing economies, breaking healthcare systems, filling hospitals, and emptying public spaces.”

Is There a Peak in Sight?

As of April 6, 2020, 4450 confirmed cases of COVID-19 have been reported in Ohio, with 142 associated deaths, according to the Ohio Department of Health.⁴ A surge in cases is expected either this week, the second week of April, or the first week of May, Abraham projected. In the meantime, the Cleveland Clinic health system has been preparing to account for 3 times the amount of patients they normally see, according to Abraham.

“We are rapidly expanding our capacity. We have about 500 intensive care unit (ICU)—beds and a 4000-bed capacity. Our plan is to double that capacity to 8000,” said Abraham. “[To this end, we have discussed] converting our newly built health science complex into a COVID-19 unit. Luckily, because of the social distancing [we have been practicing] and the flattening of the curve, we have some time to prepare for the surge.”

Meanwhile, the Tennessee Department of Health has reported a total of 3802 confirmed cases of the virus with 352 hospitalizations; notably, 356 patients have recovered from infection.⁵ “I think we're in that calm before the storm as well,” said Horn. “The prediction is the surge will happen toward the end of April here. We have incredible leadership who has been preparing for this for weeks.”

Preparation efforts have included closing down clinics and ensuring that appropriate screening measures have been put into place at facility entrances, such as taking temperatures of both faculty and patients prior to admittance. Additionally, patients who are admitted are unable to have family members with them in the hospital in an effort to prevent exposure, added Horn. Practitioners have also converted to the use of telemedicine to hold appointments with patients who do not need to visit the clinic.

Roboz admitted that the situation in New York has been overwhelming, especially with regard to caring for her patients who have acute myeloid leukemia (AML), myelodysplastic syndromes (MDS), and bone marrow failure disorders. These patients are very immunocompromised, have heavy transfusion requirements, and pose very specific challenges during the pandemic, said Roboz. Although the hope is to keep these patients safe at home, they need to come into the clinic to address transfusion requirements and other issues.

“I grew up in this city and seeing the tents pitched in Central Park for field hospitals and having the giant navy boat arrive to help us, is really quite extraordinary,” said Roboz. “I do remember the calm before the storm, and the only thing that I can tell you is that it's just so hard. One thinks one is preparing enormously, but it is quite different when the wave comes over you. Altogether, it’s quite frightening.”

Personal Protective Equipment: What’s Appropriate?

The Centers for Disease Control and Prevention (CDC) recommends a N95 or higher respirator as the preferred personal protective equipment (PPE) against COVID-19 for healthcare personnel, although they note that face masks can serve as an acceptable alternative.⁶ Additionally, all personnel should be donning a face shield or goggles, a pair of clean, non-sterile gloves, and an isolation gown.

However, according to Roboz, much of the guidance issued with regard to PPE appears to be based more so on the tools that are available rather than what is known. “It’s very disconcerting because the guidance on this, even from the World Health Organization, [has gone from that we] don't really need to wear masks [and not to] worry about it to, now, all of a sudden, everyone being asked to wear a surgical mask now that masks are actually available in the hospital.”

At Cleveland Clinic, Abraham said that healthcare personnel are not yet donning masks, although the topic has been under discussion. “My guess is that you'll go to masks sooner rather than later. Most of the guidance that we got on this in mid- or late-February end of March, turned out to be not correct,” predicted Borgen. “We know that 85% of patients either have no symptoms or mild to modest symptoms and they're contagious. If the numbers are correct, and 5% to 8% of people get hospitalized, the number of people who are walking around who either had it or have it now, is completely staggering; that’s also going to be true in Cleveland and in Nashville.”

Horn added that in Nashville, not all healthcare personnel are wearing masks either. N95s are only being used by providers who are either ruling out COVID-19 in patients or caring for those who have a known diagnosis of infection. However, surgical masks are available, and some personnel are using those masks at all times.

The other area of concern has been the question of the durability of the virus on clothing items, and although a clear answer hasn’t been provided yet, many healthcare personnel are in agreement that they should have as little on them as possible when they get home.

“I think you should leave your shoes outside the door. I think you should strip if, at all possible, before you get anywhere near your home and try not to wear things that you care about because you're going to be washing them in hot heat over and over again,” said Roboz. “My advice for today is to get rid of everything you possibly can. Get disposable clothing and watch videos on how to put on and take off PPE correctly.”

Adjusting Treatment Approaches

For the majority of patients with breast cancer, about 70% to 80%, there’s a systemic option that could potentially allow for the safe delay of surgery, according to Borgen; that’s not true for some other diseases, he added.

At Cleveland Clinic, any patient with an invasive cancer is still going to surgery, according to Abraham; however, he agreed that in certain patient subsets, surgery can be delayed by administering alternative approaches.

“Patients with high-risk, locally advanced, triple-negative or HER2-positive [disease] are still considered for neoadjuvant treatment. After surgery, if indicated, we still treat them with adjuvant chemotherapy,” said Abraham “However, some cases, like [those with ductal carcinoma in situ] or patients with locally advanced, estrogen receptor—positive, HER2-negative disease, can safely be given a neoadjuvant endocrine treatment. If needed, we can delay surgery in those patients, [depending] on [the disease] stage and biology.”

Horn echoed the sentiment that surgery can be safely delayed in the thoracic oncology space as well. For example, neoadjuvant chemotherapy can be used in a patient with a tumor that is larger than 4 cm or someone with an N1 lymph node, she said.

“I had another discussion with another thoracic surgeon in clinic who said that right now they're still able to do urgent surgeries for patients who have lymph node involvement and maybe they're going to watch those patients with the 1 cm lesions,” said Horn. “For the patients with those 1 cm lesions who are potentially surgical candidates, we might start thinking about doing stereotactic body radiation therapy rather than surgery if surgery is not an option.”

For patients with metastatic disease who have been on checkpoint inhibitors for almost 2 years, Horn said she is calling those patients and asking them if they want to discontinue therapy. By doing this, patients can be kept out of the hospital for 3 months until a scan is needed.

For patients who are in the middle of chemoradiation treatment who are about to be put on durvalumab (Imfinzi), Horn is considering modifications to the treatment schedule with the agent. Although durvalumab is usually given every 2 weeks, her team is considering just giving it on a monthly basis to limit how often patients will need to visit the hospital.

“All our long-term follow-up appointments are either being delayed, or patients are getting a scan locally and then we're doing telehealth,” said Horn. “We've just started telehealth. In lung cancer, [this is] hard to do because a patient can't tell you they have a lymph node, and sometimes you don't see it on a scan because it stops right at the clavicle and then you palpate this big [supraclavicular lymph] node. We’re leaning with our patients on [how to adjust to these changes in care].”

Roboz added that clinical trials are completely on hold at Weill Cornell, with no new accruals. For patients who were already on clinical trials and have shown to benefit from the study drug, personnel have “jumped through incredible hoops” to continue to provide them with their treatment.

“For some patients with acute leukemia, they need to be treated right away. For those patients, we are trying to see whether they can get rapid COVID testing because we do need to know immediately whether we’re going to be dealing with someone who is already infected versus not,” said Roboz. “Even for an acute leukemia with a 100,000-white count, we can sometimes temporize a little bit with hydroxyurea and just buy ourselves a minute to see what's happening with the virus. We know so little about what's going to happen with those patients that we want to get a head's up on whether someone is about to have a horrible course from COVID-19. We really may not want to hang intensive chemotherapy on that [patient].”

Many of the patients with AML are older, receiving a diagnosis between 67 and 70 years of age, added Roboz. For patients who are particularly frail, it’s important to realize that they are going to be in the hospital alone without visitors [in light of this pandemic]. “You really have to take stock of whether you think you can get that patient into remission. Will they be hospitalized for 30 days in order to get them into remission? If not, how are they going to get back and forth to the hospital? Are their kids infected? Are their grandkids infected?” This decision must made on a case-by-case basis, according to Roboz, who added that some patients might choose to opt for a more palliative course of treatment so that they do not need to be separated from their families.

For patients with high-grade MDS, Roboz said that overall, the goal is to wait for a bit before starting treatment. “Can you wait forever? No,” said Roboz. But can we try to get through April? If it's a few more weeks and we can keep them going without starting treatment, we will absolutely do that.” Patients with low-risk MDS who need count checks should stay out of the center, added Roboz. “You have to assume that by coming to the center, you will be exposed—period,” stressed Roboz. “With every single patient, you need to calculate, is it worth it? Does something need to happen at this visit that is worth the [risk of] exposure?”

The Future Remains Uncertain

In New York the projection is that there will be a peak in COVID-19 cases in mid- to late- April and then once that happens, there will be a downward slope in cases, according to Borgen; however, nothing is certain at this time.

“I have not seen any convincing evidence that this is going to peak and then blow over in mid- to late-April. I hope that's what happens. I fervently hope so, but with what I'm seeing everyday it doesn't feel like that's what's going to happen,” said Roboz. “We have to keep doing what we're doing with telemedicine. For those who aren't [where we are] yet, stop thinking and start doing. We don’t know what the outcomes are going to be, but the plan for right now is to keep social distancing, especially a population-dense environment like New York.” She added that keeping patients out of the hospital when appropriate is necessary, and for those who need to come into the clinic, isolate them the best you can.

Abraham projected that this pandemic will fundamentally change how care is delivered and how healthcare providers connect with each other and with their patients. “We need to make sure that we connect and support our colleagues. This is a completely uncharted time, and I’m so proud of my fellow caregivers and doctors,” said Abraham. “We are learning a lot about ourselves in this crisis. Everyone is coming to work and we’re all volunteering [to combat] the next surge and it’s truly amazing. It’s amazing to be a part of this community.”

Horn echoed this sentiment, saying that it has been amazing to see the oncology community come together. In the lung cancer community specifically, providers have banned together to share data on effective versus ineffective treatment approaches for patients with COVID-19, said Horn.

“It’s just amazing to watch people come to work to get their jobs done. Many are stepping in and doing the jobs that they're not normally asked to do; they're volunteering to do that work,” said Horn. “It comes from the top down and I'm lucky to be at an institution with amazing leadership. I just really hope that we can all maintain [this momentum]. Go home and see our families, kiss your loved ones, get some sleep, and face whatever comes the next day.”

Borgen stressed the severity of the COVID-19 crisis and warned all practitioners to stay vigilant and aware. “Take this very, very seriously. Don't assume this is going to bypass your town, your city, or your state. Prepare now,” said Borgen. “Open trials of treatment. Double the number of tests you think you're going to need. Double the ICU beds. Until you're in this storm, you can't imagine how the number of incredibly sick patients will double every 3 to 4 days. It's an incredible surge that we have certainly not seen in our lifetime.”

References

1. Amid ongoing COVID-19 pandemic, Governor Cuomo announces federal government is deploying approximately 1,000 personnel to New York state [news release]. Albany, NY: New York State Department of Health; April 5, 2020. on.ny.gov/3aPnvF8. Accessed April 6, 2020.
2. Amid ongoing COVID-19 pandemic, Governor Cuomo announces 1,000 ventilators donated to New York state [news release]. Albany, NY: New York State Department of Health; April 4, 2020. on.ny.gov/2XcadP0. Accessed April 6, 2020.
3. Schwirtz M. The 1,000-bed Comfort was supposed to aid New York. It has 20 patients. The New York Times; April 3, 2020. nyti.ms/3aQq0Hl. Accessed April 6, 2020.
4. Resources for local health districts and providers — COVID-19. The Ohio Department of Health website. Updated April 6, 2020. bit.ly/2XipEoX. Accessed April 6, 2020.
5. Coronavirus disease (COVID-19). Tennessee Department of Health website. Updated April 6, 2020. bit.ly/2UKrBsy. Accessed April 6, 2020.
6. COVID-19 personal protective equipment (PPE) for healthcare personnel. Centers for Disease Control and Prevention website. bit.ly/39H4FPi. Accessed April 6, 2020.