Dr. Sandeep “Bobby” Reddy joined me on my podcast for the American Journal of Managed Care to discuss the clinical care of cancer patients in the age of COVID. Dr. Reddy is an oncologist at the UCLA School of Medicine and the Chief Medical Officer of NantHealth, a healthcare cloud-based information technology company that converges science and technology through a single integrated clinical platform.
What follows is a modified version of the transcript of the interview. It has been abbreviated and edited for readability. Some sections have been omitted altogether (e.g. growth factor use, and participation in clinical trials) but can be found on the podcast recording.
Scroll down to view a 5 min video of Dr. Reddy discussing the most important things you should know about getting cancer care in the age of COVID.
PS: Are cancer patients at increased risk to get COVID-19?
BR: It’s an interesting question, however, despite so many cases and so much time that’s elapsed, the answer, unfortunately, is we don’t really know.
What we do know is that cancer patients are at higher risk of mortality if they do contract the virus. And that is true for patients who are actively being treated and as well as patients who have recovered from treatment.
There is data from both China and Italy that shows a very significantly increased risk of death in cancer patients and post-cancer patients. The thought is that because of the immune compromise, they will develop a more severe form of the disease and end up having hospitalizations, ICU stays, and ultimately an increased risk of mortality.
We would surmise that those same factors would also lead to an increased risk of contracting COVID. However, we haven’t actually seen that epidemiologically.
So far, it seems like the cancer population is being affected at about the same rate as the general population. That could be because cancer patients are taking even greater precautions to avoid contracting the disease.
And, perhaps, the people around them, their caregivers, and other members of the community are also behaving appropriately in terms of social distancing, wearing masks, and the other protective measures that we can take.
PS: Should cancer patients use N95 medical-grade masks to protect themselves?
BR: That raises an interesting point about the use of masks and this big debate that we’re having in the country. Remember, masks don’t actually protect the wearer. This is a great misconception. The purpose of the mask is to protect everyone else.
If we as a society wore masks, meaning everyone, maybe for a month, we would probably have zero COVID. This is because the virus would not be able to spread and infect new people.
When you cover your face with the mask, it effectively reduces transmission by about 99%. This is true, no matter which mask you wear.
The N95 mask is a tight-fitting mask that reduces the likelihood of any viral particles getting to a wearer. However, the critical reason that we should all wear masks is to prevent transmission.
If you cough or sneeze or even breathe very heavily, all of the virus particles that will be expressed from your mouth or nose will be trapped by the mask. So, somebody else who’s nearby will not contract the virus.
Even if a tiny fraction of viral particles does get out there, that’s probably below the threshold that’s going to cause a very severe infection. So the type of mask is more or less irrelevant. The key is covering the face.
People must understand that you don’t protect yourself by wearing the mask. You’re protecting everyone else.
If you enter an environment where you have a mask but everyone else doesn’t have a mask, that’s a dangerous environment. People just need to be cognizant of that fact and know that they need to definitely appropriately socially distance. They also probably should insist on others around them wearing their masks or face coverings and taking the right precautions.
PS: What should a cancer patient know before going to a medical facility?
PS: People with cancer cannot completely avoid going to a clinical setting, such as a doctor’s office, an infusion center, a hospital. They must get their treatments and have complications looked at. What should a cancer patient know before going to a medical facility?
BR: We’ve learned a lot of things from COVID that I hope will be continued after the pandemic. For example, we’ve taken safety to another level, including the use of PPE for healthcare professionals and also patients.
It also means triage screening of patients. What do I mean by that? When my children were young, we’d take them to the pediatrician. There were two waiting rooms: one for the sick and a different one for the healthy.
In normal times, adult doctors, including oncologists weren’t doing that. Now, to varying degrees, we are trying to physically separate patients so that they can be contained in a safe environment.
For example, when patients have an outpatient appointment, we don’t ask them to come in and wait in a large room with others. Instead, we ask them to wait in their car. When we are ready to see them, we text them to come in directly to Exam Room 3 or Exam Room 4. That way they have minimal contact with others.
Checked-in now takes place in a single location away from others. And, patients get their temperature taken. They are then triaged based on whether they are a high-risk person or a normal-risk person.
These practices are critical now. But going forward they can be useful to reduce the risk of other infections, such as the flu. Remember, flu also causes a significant number of hospitalizations and even deaths every year.
So in summary, patients should be aware of the following:
- Good safety practices are being put into place. That means we use PPE across the board and insist that everybody wears a mask.
- There also should be some triage mechanism so patients know that they are not going to be exposed to someone else who may be infected. That way they can feel safe and comfortable in the environment.
PS: Should cancer patients be tested for COVID before their surgery?
Dr. Reddy: Absolutely, it should be done before elective but necessary surgery. At the very onset of the pandemic, many hospitals were putting off elective procedures. We were deferring them too. In fact, even today, anything that can be deferred should be deferred until you know that it’s a really safe environment.
On the other hand, if there is an emergency, we have to deal with things as they come up. If there’s a car accident, for example, you don’t have time to test before surgery.
We also should understand that everybody involved in the care of a patient needs to be routinely screened. Many businesses are doing routine screening of their workforce now. They are catching people who may be asymptomatic but actually have the virus. Then they can send those people home and they can avoid risking infection across their whole enterprise.
These types of mechanisms are now in place. We’re not doing that across the whole healthcare continuum because we can’t. It’s too expensive. But we can do it in bits and pieces where the highest risk exposures are.
For example, in the ICU we really want to minimize the risk of exposing patients to COVID. Therefore, we need to test the nurses who work there and screen them to make sure they’re not exhibiting signs and symptoms of the disease.
Lastly, I would also say in the nursing home setting, where we’ve seen really horrendous mortality amongst nursing home residents, putting in place strategies to screen visitors and the healthcare workers makes sense. We need to make sure that we’re not infecting our nursing home populace. Equally important is being sure these people will not take the infection from there and spread it into the community.
In conclusion, a lot of measures have been put in place. We just have to respect them and make sure that we follow those rules and guidelines.
PS: What’s is it like to be a cancer patient in the age of COVID?
PS: What are you telling patients in the middle of chemotherapy or other cancer therapies, say radiation therapy for example, about their safety, their risks, any delays that would be considered acceptable, and so forth?
BR: It depends on the goals of therapy. Certainly, we have attempted to partition the patients into two groups:
- Those who we’re treating with curative intent, that is we believe we can cure them. For those patients, we’re going to push to not make any changes whatsoever because we are pushing for a cure. That is critical. That’s our first and foremost goal. We have a limited opportunity to do that in a patient with a cancer diagnosis, so that’s our primary motivation and concern.
- On the other hand, for patients who we’re treating for palliation of their disease, we have to weigh the risks to benefits. Does intensifying their cancer treatment come at a higher risk of mortality from COVID?
When we look at those scenarios, the equation is a little bit different. We ask ourselves some questions:
- Can we delay treatments?
- Can we change the schedule of treatments? For example, can we space them out allowing the patients to have less contact with the healthcare system?
- Can we add oral therapy to replace IV therapy so that, again, patients can be at home and have that convenience?
- Can we schedule laboratory visits to be an outpatient or a home visit, home phlebotomy, to avoid the patient coming in contact with the healthcare system?
There’s a lot of things that have changed over time to allow us to do that, and we’re taking advantage of that now. I think for those patients who are in the middle of therapy, that’s how we approach it, for sure. We want to triage them. Those who we think we can cure, we’re going to push to do that. Those who maybe we can’t, we want to be cognizant of the fact that there’s a virus and we want to tailor those treatments. But it’s on an individual basis, of course.
PS: Are patients who are at the palliative therapy stage of their disease accepting of a delay or other changes to treatment?
BR: For the most part, we’re not going to delay people for an extended period of time. We realized early on this virus isn’t going away. This is going to be a very significant problem that’s going to last for a long time. We can’t just say, “Well, we’ll wait six months.” That’s just not acceptable with this disease. So, we are getting people started on therapy.
But, we might start somebody at a slightly lower dose because we’re cognizant of the fact that a really high dose may significantly increase their risk of getting a neutropenic fever or getting infected and ending up in the hospital. So, we might start them lower and then increase.
Patients understand the risks and benefits. We always try to have that very detailed conversation upfront. I think some of the differences are certainly that during the pandemic, it’s been I think a more isolating experience for the patient.
PS: How has communication with patients and families changed because of COVID?
BR: In the past, it would be very routine if somebody was newly diagnosed and you saw them as an inpatient consultation in the hospital, you would have a big family meeting because lots of people would be visiting. Now those visitors are no longer allowed in the room or in the hospital at all. Now, that conversation is often happening as one-on-one.
We are taking advantage of telemedicine, certainly. We have telemedicine visits with patients. And, we are also trying to do that with family members no matter where they live. Having them involved in that conversation has been really beneficial.
In the past, it was very difficult to do this. You’re very busy as a physician. Can you be calling everyone back? Now, you can just schedule a time and say, “We’re all going to have a Zoom, we’re going to get on at such-and-such time, and we’re going to talk through the issues,” and everyone’s questions are answered.
So it’s different. Is it better or is it worse? It’s hard to say. I think over time we’ll figure out what works and what doesn’t. But that is one difference I can tell you.
PS: What else has changed in terms of treatment plans?
BR: The other difference I can tell you is that one of the things that we’ve done across the board is the shortening of therapy. What does that mean? There are certain radiation schedules that can be reduced by perhaps increasing the dose slightly. We change the treatment plan to what’s called a hypofractionated radiation schedule.
There are certain clinical trial data that try to answer questions like these:
- Do you need to take a year of therapy or could you get by with six months?
- Do you need to take six months of adjuvant chemotherapy or could you get by with three months?
We are looking at reducing the length of time for some patients going on therapy because the data say the results are almost the same. Should we try to decrease someone’s exposure to toxic medicine during COVID? Yes, we should. That I think you’re seeing across the board, across multiple diseases.
PS: Is COVID driving changes in the healthcare delivery system?
BR: I think absolutely it is. However, this is a very unique situation and I don’t want to paint it with too broad a brush. In April, when oncologists in New York City were under siege, it was reasonable to consider opting for a regimen that might have a lower efficacy if it had a lower risk of hospitalization, infection, and complications.
However, an oncologist in Phoenix at that same time certainly would not have chosen that because there was no risk in the general populace in Phoenix then. Now, of course, that has completely flipped.
I think what’s important is to recognize this is a very dynamic, changing situation. The knowledge that there might be a bed available in the hospital, including in the ICU absolutely informs our decision-making.
Prior to the pandemic, I never paid attention to the hospital’s daily census. Now I receive it as a text message that lets me how many ICU beds are available. This information is ever-present in the back of my mind.
PS: What about telemedicine?
BR: The pandemic has really brought telemedicine to the forefront. We have the ability to coordinate care virtually in a way we never could do before. For example, you can include multiple family members and multiple doctors on a telemedicine visit.
It also untethers you from a location and even a set time. It allows things to be attended by more people, a broader spectrum of people. And, it allows you to disseminate information across a broader group of people.
That’s a big advantage, and it’s my fervent hope that we do carry some of these lessons forward once the pandemic ends.
PS: Absolutely. This was facilitated in part by congressional actions that reduced some barriers to telemedicine that had been hard to break down, like having to have a license in every state, not getting paid as much as if it was an inpatient visit, all those things.
Of course, they’re all on the line again, so I hope everybody that’s listening will pay attention to this and contact their representative and make sure these barriers that were brought down remain a part of how telemedicine is conducted so we can really take full advantage of it.
PS: Many people are fearful of being in a health care setting right now. Are they delaying necessary care? What do you advise someone who discovers something worrisome, for example, a new breast lump?
BR: We know that there’s been less utilization of healthcare services, particularly at the beginning of the pandemic. It was, in part, because there was a broad appeal by hospitals and even the government saying:
“Look, if you’re not sick, don’t overtax the system because we have to get ready for a giant surge of COVID patients.”
As I said, in certain locations that has been happening on a rolling basis across the country where we’ve seen hospitals fill up.
But in other locations, it hasn’t happened. Certainly, people should feel very comfortable presenting to their doctor even for routine care. But a lump or something concerning that’s potentially malignant needs urgent evaluation. That should not be delayed. I cannot overstate that it’s safe to go to your physician.
The initial evaluation can be done safely for the most part in most places. You can at least get that biopsy, you can get that x-ray, CT scan, ultrasound, whatever, to have the area of concern checked out. I would not want somebody to delay that.
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But we do have the evidence that people have been putting off care. And, it’s been occurring not just in cancer but across all diseases. There are certainly fewer diagnoses occurring than the expected rate. For example, I recently saw a headline in the news that said, “Where are all the MI’s (heart attacks)?”
It would be great if it turned out that the populace got much healthier and there’s going to be less cancer and less severe illness. But that’s unlikely.
It’s probable that there have been delays in seeking care. I really hope that everybody listening understands, if you’ve got a problem, you’ve got to go take care of it. Delaying it is not going to be helpful. It’s going to be harmful.
We think that at some point there will be a flood of catchup as these new patients come in. Then we will need to play catch-up. We must be prepared for more surgical procedures, more diagnostic procedures, more definitive treatments.
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Let me say it again, it is safe to go to your doctor and get treatment as long as your doctor is following the guidance we talked about earlier. That is, have PPE in place and they have a triage system.
It should be safer than probably a lot of the other places like we talked about when you’re out in the community and people aren’t wearing masks. You’re much safer going to the doctor, where everyone’s wearing a mask, everyone’s being checked out and monitored.
PS: Thank you. Very powerful message. I hope everybody who is listening, if this is a concern of yours or somebody you know, that you take this to heart.
If you need to get care, go and get care. It’s safe.
PS: What do you tell cancer patients when they ask “what can I do to strengthen my immune system?”
BR: That’s a really good and difficult question. We know that people do a lot of things that don’t work. They often use herbs and other supplements. Echinacea is very popular. These may cause minimal transient changes but are not going to be really meaningful changes to improve somebody’s immune function.
Good overall physical and emotional health
The most important thing is to maintain a generally good overall health status. This includes overall emotional health wellbeing. The latter is very difficult during these very stressful times when people are besieged by not just the pandemic, but all kinds of other social unrest and other things that are happening. We know that emotional wellbeing is actually very critical for the immune system to function.
Anything that can relieve stress is absolutely critical. I tell my patients stress relief is important, whether that be prayer, meditation, yoga, you name it. Whatever it takes. But that’s critical.
I think exercise is critical. Yes, you can get out. Yes, you can go exercise. The gyms are closed, but that doesn’t mean you can’t exercise. Physical activity, exercise, getting some vitamin D from sunshine, some fresh air, those are all very helpful.
I’ll give you a specific example of some of the things we are avoiding. That is medications that can adversely impact immune function.
There are also medications we can give that can improve it. When we think about our patients, for example, who have had an autologous stem cell transplant, we give them maintenance therapy post-transplant.
Strategies to manage the use of maintenance therapy
Maintenance therapy can be associated with immune suppression, so we’re very careful to be picking and choosing those patients. Patients who have been on maintenance for a while and have exhibited no signs or symptoms of relapse whatsoever.
However, we do monitor them for something called minimal residual disease. If it looks like they’re really in true remission and have been so for a while, we might shorten that course of maintenance.
There’s a drug called rituximab which we might give for three years after an autologous transplant for a mantle cell lymphoma patient. It’s really only of very marginal benefit in terms of reducing their risk of relapse.
If it’s been a couple of years, we have patients who we’re taken off maintenance right now because we know that drug, in particular, depletes their B cells, which are a type of lymphocyte which you need to fight off a viral infection.
Similarly, patients who have CLL (chronic lymphocytic leukemia), will be given pooled immunoglobulin, IVIG, to help them fight off infections including pneumonia.
Convalescent plasma may also help people fight COVID. We’re certainly using immunoglobulin now in those patients, but now I’ve been measuring it in other patients to see if they’re low. If they’re very low, I’ve been supplementing their immune system with that to help them through this period.
There are things that we can do medically
But I think the most important thing for patients to do is be safe, be healthy, eat healthily, and definitely reduce your stress and try to exercise. Those are things that are all within their control, so I definitely motivate them to try to do that.
Are there any new insights about cancer – its etiology, its treatment, its natural history – that we might have already learned from COVID?
BR: I can tell you that, for example, within the Nant family of companies, we’ve been actively involved in a cancer vaccine program using an adenovirus backbone, similar to the Moderna vaccine. That kind of learning from the cancer arena is being transported into the infectious disease arena.
And vice versa. For example, there are good reports from both Italy and China on using stem cells to reverse the tissue damage done by COVID-19, particularly in the lungs. That becomes a very, very exciting opportunity to reverse some of the forms of severe tissue injury that we see in cancer patients, let’s say from radiation or chemotherapy treatments.
Certainly, the regulatory environment right now is a little bit different and is allowing the pace of clinical trials and new developments to perhaps go a little bit faster than they would otherwise because of the acute need. That will allow us to gain new knowledge, which hopefully will take us into new places not just in cancer but other diseases.
PS: That’s great to hear. I’ve been through so many rounds of healthcare reform in my career. I believe that COVID-19 is doing something that no amount of health policy gurus has been able to do. That is, disrupt the system enough that we’re starting to put in new, hopefully, more effective approaches. And, I agree with you, we don’t want to see a reversal of these innovations after the pandemic is over. Rather, I hope we will continue to evolve our system to better meet the needs of our patients and our communities.
Thank you very much, Dr. Reddy, for a wonderful conversation.
You can listen to the full interview here: https://www.ajmc.com/view/cancer-care-in-the-age-of-covid-19-dr-patricia-salbers-interviews-dr-bobby-reddy