Rini Shares Challenges in Keeping Up With COVID-19 in Oncology

Brian I. Rini, MD

A plethora of new challenges have arrived in routine cancer care amid the COVID-19 pandemic for oncologists, including but not limited to halts in clinical trial development, limited uses of immunotherapy, and rapidly changing procedures and evolving data, explained Brian I. Rini, MD.

“What was true last week might not be true now,” said Rini of how quickly policies in clinical practice are changing due to the outbreak. “We're all trying to do the best we can for people, but it's hard to do that when the data and the information changes day to day.”

In an effort to share some of the evolving knowledge about the virus and how it is impacting the healthcare system on a global scale, members of the Uromigos group on Twitter have been discussing statistics, strategies, and new studies as they relate to COVID-19 and patients with cancer. In addition to Rini, the account is run by Thomas Powles, MD, MBBS, MRCP, of Barts Cancer Institute; Silke Gillesse, MD, of the University of Manchester; David F. McDermott, MD, of Beth Israel Deaconess Medical Center; Christopher Sweeney, MBBS, of Dana-Farber Cancer Institute; Srikala Sridhar, MD, MSc, FRCPC, of Princess Margaret Cancer Centre; Laurence Albiges, MD, PhD, ‎of Gustave Roussy Institute; and Cristina Suárez Rodriguez, MD, of Hospital Quirón Barcelona.

Moreover, in a recent series of podcasts by Uromigos, the 8 oncologists have covered the clinical efforts with tocilizumab (Actemra) and hydroxychloroquinine in patients who test positive for COVID-19, preventive measures across institutions, and considerations for using immunotherapy in patients at risk for developing the virus.

In an interview with OncLive, Rini, inaugural chief of Clinical Trials at Vanderbilt-Ingram Cancer Center, highlighted the Uromigos podcast efforts to educate other oncologists on how COVID-19 will shift their practice, as well as adapting to changing procedures in clinic to continue delivering optimal care for patients with cancer during the pandemic.

OncLive: You're part of the Uromigos group on Twitter, where you and your colleagues have been discussing COVID-19 in a series of podcasts. Could you highlight the multimedia work you have done?

Rini: We started Uromigos podcasts a couple of months ago. We first focused on light-hearted coverage of genitourinary oncology topics. In the last 10 days, it's quickly turned to more somber COVID-19 coverage. We have probably done about 5 COVID-19 podcasts. We did one with a respiratory therapist from London, who is a colleague of Dr Powles. We did [another podcast] amongst ourselves because we have global representation; we discussed how each country was handling it and where they were on the curve, so to speak. Our best one was on hydroxychloroquine, for which there are a lot of "data" and mostly hype about its use. We talked about it with an investigator from Minnesota who was doing a healthcare worker prophylaxis study.

Then, we talked to a Seattle intensive care unit (ICU) physician doc about tocilizumab. We're trying to just cover the waterfront—anything and everything of relevance to COVID-19, number one, and specific to cancer patients, of course. We did do one on immunotherapy with Charles Drake, MD, PhD, and Doug Johnson, MD, MSCI on the theoretical concept, "Is immunotherapy good or bad for the virus?"

One of the hard parts is that this is changing by the day, if not by the hour. It's really hard to give sound advice that's going to persist. We're trying to just give generalities and conceptual things and try to spread some good information.

Where do you recommend people listen to the podcasts?

It's on a few different platforms; most people have Apple podcasts and it's also on Spotify. Those are probably the 2 most popular [platforms], and there are others that I'm frankly less familiar with.

In Uromigos, you and the other members are all from different parts of the globe. How have you been dealing with this pandemic in different ways?

It's nice to have ready access to other people around the country. [I have thought about what this would have been like] if this had this happened 20 years ago, when a lot of our social and other channels of communication were so wide open. Therefore, 1 of the good things that has come up is that the information flow is unbelievable—it's too much, in a sense. At the end of the day, I'm pretty mentally spent from trying to process information.

There are so many parallel work streams, conference calls, and Zoom calls. We're trying to move things forward, which normally happens over weeks to months; now, we're trying to move forward over minutes and hours. That's a challenge. As I was saying, though, it's good to have people from other parts of the globe to sort of understand, and ask, "How are you dealing with it?" Obviously, France and Spain have sort of hit their surge, and hopefully, they're getting past it. [We find out] what they are they using, we're sharing best practices, and that's happening not just in our group, of course. There are just massive email chains of different groups of doctors—lung cancer doctors and immunotherapists, and whatnot, who are sharing information and sharing practice guidelines, because we're all desperate for information. Everybody realizes that there's no one right way to do this. A lot of the guidelines are fairly similar, even if they're not based on the most solid data.

Earlier, you discussed the hesitation with immunotherapy and whether or not it will [impact the risk of getting COVID-19]. What have you been doing in practice so far as it relates to immunotherapy? Are you reducing use of this type of treatment?

I think most people think of it as, if somebody's already on a regimen and they're doing well, it probably makes sense for most people to hold some doses—just to keep them out of the infusion room for the next several weeks. For somebody who is on [a checkpoint inhibitor] for 1.5 years, then by definition they're doing well. One could probably hold a few doses of drugs, it is probably still in their system and their T cells are probably still saturated with drugs.

Most people are taking pauses in therapy, not just with immunotherapy, but with any therapy when it is clinically possible. [It is tougher for patients who are just starting on therapy]. In kidney cancer, there are many patients who can be watched, and whether they start therapy now or in 1 or 2 months, it's probably not going to impact their outcomes.

Normally, we would delay those patients, but now I'm super motivated not to start them on some aggressive regimen. It gets a whole lot trickier when you're talking about diseases that require more immediate treatment: lymphoma, germ-cell tumor, and some solid tumors that just have symptomatic disease. Now, we're putting the risk of COVID-19 infection into the risk-benefit equation, which obviously we never did before.

There must be a greater concern with developing immune-related adverse events, such as colitis and pneumonitis. If they reach a grade where these patients need to go to the hospital, then they're increasing their risk of being exposed, correct?

If a patient is coming in as an outpatient to get infusions, they have a risk of complications: requiring immunosuppressants like steroids, or inpatient admission, both of which you want to avoid at all costs. If there's 1 place where sick people gather, it is at a hospital. You have put a little bit of thought into that before, but never to this degree. That risk then is balanced against the benefit.

What about adjuvant therapy that has a 5% overall survival benefit? Is that worth it? If a 70-year-old patient gets sick with COVID-19, they're in trouble, right? Their mortality is 10% to 20%. Therefore, that's much higher than that 5% benefit. These are the equations that people are evaluating, and frankly, we are constantly reevaluating.

Are you also exploring giving patients different methods of therapy, such as oral medicines versus intravenous formulations?

In my role with clinical trials, we're getting a process in place to ship investigational drugs. It's sort of a routine: toxicity check, pick up your oral drug, and go home. We're doing that with telehealth and drug shipment. Some patients have infusions though, and there's no oral equivalent, so those patients have to come in if you feel they need treatment. These are difficult times to care for people, let alone caring for the people who get sick. Just your routine cancer care has become very difficult.

This opens up another host of issues with clinical trial development. How is enrollment being affected?

Some centers have shut down enrollment entirely. We have a prioritized list of studies that. We shut down sort of non-essential research: questionnaires, non-interventional, and non-treatment studies—just to limit contact for the study staff. Most of our study staff is working from home now. We're keeping it going with the skeleton crew, but honestly, we have calls every day to reevaluate that. It's sort of an all-hands-on-deck approach to try and figure it out.

The problem is that, for some people, this is their best therapy, right? If you believe in doing trials, you believe that is a patient's best option. You're weighing that against shutting things down, and people may not have wonderful standard of care options. It's really an individual disease and patient decision.

How are you currently handling hospital shortages in terms of beds, face masks, etc.?

We're just concerned about the number of beds, number of ventilators, number of ICU units. That's what everybody's concerned about, obviously. We're preparing as much as possible, and we're ahead of it, but everybody thinks you're out [ahead] of it until you're behind it.

What is the telemedicine process like in your clinic currently?

We are doing telemedicine whenever possible. Since I just started a few weeks ago, I don't have a busy clinic; most of my day is on Zoom calls about COVID-19. We probably have 6 or 7 different COVID-19—based research initiatives, at least going on well, prospective trials. We have a large, international database translation. That field has exploded in a week; everyone is trying to think how to solve this problem. How do we learn from it? How do we gather data?

It will be weeks to months, if not longer [until there is a solution], but a lot of people are thinking about this problem. There will be advances, and we'll be smarter for when the next time comes; everybody in the world was clearly unprepared for this. There are going to be a lot of postmortems on this and a lot of lessons learned, but there'll be some good that comes with it.