Transcription:
Cancer in the Time of COVID-19

John Leonard, MD (Host):  Welcome to Weill Cornell Medicine CancerCast, Conversations About New Developments in Medicine, Cancer Care and Research. I’m your host Dr. John Leonard. And today, we will be discussing the timely topic of cancer in the time of COVID-19. Today’s guest is Dr. Adrienne Phillips. Dr. Phillips is a Hematologist and Medical Oncologist at Weill Cornell Medicine and New York Presbyterian Hospital. She cares for patients with all types of hematologic malignancies or blood cancers. She has a special interest in treating lymphoma patients requiring stem cell transplantation. And she also is an expert in aspects of reducing cancer disparities by improving outcomes among underserved and minority populations especially among Latino and Caribbean Americans. So, Adrienne, it’s really great to have you here today. Thank you for joining us.

Adrienne Phillips, MD, MPH (Guest):  Thank you Dr. Leonard for the invitation.

Host:  So, there’s a lot happening and before we really get started, I want to advise our audience as I have done whenever we talk about COVID, the world is changing, things change quickly. We’re recording this in the end of April but by the time someone hears this, depending on when you listen to your podcasts, you may be in a little bit different situation meaning that the world might have changed. Also you might be in a different part of the country. We’re based in New York, but I think most of what we’re talking about and is applicable to people really anywhere in the US or other parts of the world because of the nature of this COVID epidemic that we’re all dealing with.

So, the most common question I get Dr. Phillips is the issue around what is the risk of cancer patients as far as their immune system? Patients who either have had cancer many years ago and had treatment, might be in the middle of treatment, might have been diagnosed but have not yet had any treatment. And the concept of being immunocompromised if you’re a cancer patient. I know you are a stem cell transplant physician in part and those patients are even more immunocompromised perhaps than others but what do you tell patients in general about the immune system and the immune status of someone with cancer and their risk of getting an infection whether it’s COVID or something else for that matter?

Dr. Phillips:  Right. So, I would say, in general, cancer patients are at higher risk and certainly there are patients that are at the highest risk and those that maybe have moderate or less risk but as an adult oncologist, most of my patients are an older population so we know that older patients are at risk for COVID infection but then cancer patients in particular because if they have active cancer, first of all, their immune system particularly if they have a blood cancer for example a leukemia, lymphoma, multiple myeloma, their immune system is suppressed and then if they are getting chemotherapy, particularly chemotherapy that’s lowering their blood counts, if they are requiring growth factor support for their chemo regimen, they are instructed to always monitor for fever and signs of infection but during this COVID time, I would say those are the patients that are at higher risk and like you said, my practice is primarily bone marrow transplant or stem cell transplant patients and those patients whether they’re pretransplant, going through the transplant within the first 100 days; I would say they are at particular high risk for COVID infection.

Host:  So, from the standpoint of being a patient who perhaps is dealing with breast cancer, lung cancer, different types of cancer that you and I typically deal with being blood cancer specialists, would you also consider those patients at least some higher risk and being a group that should take whatever precautions or concerns a little more seriously than the average person as well?

Dr. Phillips:  Right, so a little outside of my expertise but I would say patients like you described that have what we call solid tumors, so breast, lung, colon, particularly if their cancer is active during this period, if they are getting chemotherapy; they would also be at higher risk and I know there’s a small study from Wuhan where this pandemic started that did publish on about 100 patients with all types of cancers and they did find that patients, particularly with advanced stage cancers, stage III, stage IV solid tumors were at higher risk for COVID infection. But again, we’re kind of learning as we go with this Novel infection and we should look to prospective studies to kind of gauge if patients with a variety of different cancers are at the same risk or not.

Host:  So, from the standpoint of a patient kind of sitting there saying hmmm, I’m concerned, I’ve heard that cancer patients don’t have a perfect immune system, I like to say, most of my patients have an imperfect immune system, there’s obviously a range of that but would you say that patients should really talk to their doctor and their provider to say where do I fit amongst these different categories or are there any other kind of rules of thumb you give people?

Dr. Phillips:  I would absolutely have patients check in with their doctor, their provider, their healthcare team to kind of gauge their risk, particularly maybe if they haven’t been recently within the last six months perhaps, hadn’t had a visit, maybe just give the office a call. We might talk about Telemedicine going forward, but we’re certainly available to answer questions and this is a time where I know many patients are feeling insecure. There is a lot of uncertainty. So I would say if there’s any doubt about your risk for COVID, check in with your doctor or their office.

Host:  So before we get into COVID more specifically, I think in my practice, one of the most common things whenever a patient has had an infection ; the question comes up well what can I do to prevent this. Cancer patients are always asking what can I do myself. Is there a supplement I can take? Is there a diet I should have? The first question is always what can I do to prevent my cancer from coming back but usually that’s followed by what can I do to boost my immune system. Is there anything a patient can do to boost up their immune system or is it just basically the precautions of staying away from risks so to speak?

Dr. Phillips:  Well there’s certainly some things that are not necessarily medications or supplements that I would certainly advise. So, everyone should have a full nights rest. They should keep their fitness and physical activity level and their routines up as much as possible during this time. We always recommend a balanced diet. In terms of supplements, that’s something patients should talk with their providers about because certainly some particularly in excess amounts could cause more harm than good. But I would say the general recommendations are kind of what your mom teaches you, to get a good night’s sleep, eat well, get your exercise, and for anything else again, check in with your doctor. I’m curious, what do you suggest for your patients regarding boosting their immune system?

Host:  I think it’s a great question. We have some exceptional patients. I know you have some of those who have very profoundly suppressed immune systems who might need to take an immune protein called gamma globulin which is an antibody or an immune kind of replacement treatment. That is pretty rare. That’s not really something that’s applicable for 99% of patients with cancer. And I would agree with you. I think it’s trying to be healthy, it’s trying to sleep well, take care of yourself. I think moving around is very important as we’ve learned. I mean one of the most common infections even without COVID is lung infections. We know that stretching out your lungs so to speak, walking around and doing things as opposed to lying in bed is going to reduce infection risk.  Getting into a chair rather than a bed is better than being less mobile. So, I would agree with your advice there.

Dr. Phillips:  Yeah and I would also add I guess during this time of social distancing and some restrictions on going outside to outdoor spaces and large groups. I mean there are certainly somethings people can do in the home just whether it’s stretching or walking up and down stairs or walking your pet or playing with grandchildren. I suggested that to a patient recently. So, there are certainly some things you can do even with social distancing to keep your fitness level up.

Host:  So, I want to move to kind of the specific advice that we give patients around this time of COVID, although, certainly with your patient population of transplant patients, this is probably advice that you give routinely even when we weren’t aware of or dealing with COVID as far as avoiding infections and we wont spend a lot of time about the details of COVID. But just to remind everyone COVID is a type of virus called a Coronavirus that is typically gives respiratory infections and is typically transmitted we believe by respiratory droplets, coughing, sneezing, being the primary way that it’s transmitted. But we’re still learning, and other areas of contact could potentially be a component of its spread and it’s also something that is transmitted by various surfaces. So, if those droplets get onto a surface, and then one comes into contact with that surface and then brings that into one’s face or mouth, that could transmit the virus.

So, Adrienne, how do you tell your patients from the standpoint of how to prevent this? What can they do to prevent this as well as other infections and we can’t forget things like influenza and other respiratory infections that people can get particularly when they are immunocompromised?

Dr. Phillips:  Right, so, like you said, my bone marrow transplant patients are at risk for a number of different infections, not just COVID. So, we frequently particularly if they are within 100 days of transplant, encourage them to be isolated. Right after discharge, we keep them close to the hospital and we have them really only with one identified caregiver, trying not to introduce too many people to their environment. We encourage what we call here in the hospital hand hygiene so, consistent washing of your hands for at least 20 seconds singing the happy birthday song twice with warm water and soap and then if you aren’t able to wash your hands have some alcohol based sanitizer available to always kind of wash your hands off if you are touching surfaces frequently.

If someone has respiratory symptoms, it’s again kind of what you learned as children just cover your mouth when you cough, don’t cough directly into the air. Try and avoid crowds as much as possible. The surface question is interesting and I definitely had patients ask me how often do they need to wipe down surfaces, wipe down their groceries, their cell phone, their other things that are in their hand and I don’t think anyone knows, but I think it would be helpful to have disinfectant wipes around the house to kind of periodically wipe down surfaces but that’s generally my advice for transplant patients and I would say for people experiencing this pandemic as well.

Host:  Obviously trying to avoid crowds or avoid going to the grocery store or taking public transportation if you don’t have to is probably a good thing. But obviously some people need to do that. They live alone or don’t have someone to do their shopping or need to go somewhere. What advice do you have for people beyond handwashing and masks?

Dr. Phillips:  Right, so if they absolutely have to, I mean I understand they need to get their food products. I know that certain stores have allowed for certain hours for older people, for immunocompromised people, maybe they can reach out to whatever store they’re ordering from if they have any delivering service. But I would just say try and maintain your distance when you do have to go into these public places. Consider wearing not just facial covering but also gloves and just wash your hands right when you get home.

Host:  So, one question that patients that are concerned about COVID and having cancer is how should this affect my treatment, my care, my doctor visits? Many cancer patients and patients in general are experiencing as are the providers, the physicians Telemedicine and are using technology to communicate, to have visits with their physicians or healthcare providers and that goes some ways and has some advantages for everyone but obviously doesn’t cover the whole waterfront of possibilities and situations. So, what advice do you have for patients where the doctor says you need to come in to be seen, we need to check your bloodwork, you need to have treatment; how have facilities and treatment centers been dealing with this to keep people safe? Because obviously it’s an important issue that we’ve all spent a lot of time on and I think it’s important that patients understand that they can get care and they are able to be treated safely if they need it.

Dr. Phillips:  Right. So, COVID has kind of put the whole world on pause but other health conditions continue to exist, and a person’s cancer is not necessarily on pause and certainly needs to be evaluated. So, I know here are our practice, we have really ramped up our Telemedicine service. I believe most of our visits now with patients if they can be done this way are via Telemedicine and we’re able to see the patient on video and sometimes even order blood tests at a local laboratory that can be sent into us to be reviewed. So, we’re certainly using Telemedicine but like you said, some people do have to come in and again, here at our institution, we were rapidly able to designate certain spaces within our practice for evaluation of patients who we had a suspicion for COVID where they could quickly get swabbed and triaged to the right service. We have treatment areas that are for COVID positive patients to get their treatments, their transfusions, their chemotherapy and then for those that are COVID negative, we also are able to separate them out to a unique space in our facility. So, kudos to our division and our hospital and our leadership for rapidly being able to negotiate that. And I think patients again with cancer, their cancer is not on pause during this pandemic so they need to again talk with their doctor and certainly if they need to be evaluated, they should come in and we are evaluating each case on a case by case basis but certainly if someone needs treatments, someone needs surgeries, someone needs inpatient care; there’s no change.

Host:  I would echo that. Before we started our discussion, I was just down in the clinic and infusion center seeing a patient and it is a much smaller number of patients because people are being handled in a very careful way and as you said, many patients are undergoing and using Telemedicine but there are a good number of patients getting what they need and really in a very comfortable and safe environment and the staff is all attuned to their needs and what precautions need to be followed and I think things are going very smoothly in our center and I know many other centers are also taking all of these things into account.

I want to turn to kind of the bigger picture of rather than the specific precautions or measures that are being taken to ensure a safe environment to get care and really talk about how we think about patients in the setting or perhaps in the middle or just diagnosed with cancer in this context. Are there patients that you are putting off treatment and are there patients that you’re saying well, we can still do this very safely or we don’t have a choice, we have to move ahead? How do you advise patients and obviously this is a very individualized decision, but what goes into the thought process of making a decision around do we start treatment just as we would in a regular timeframe or do we maybe delay things a little bit?  

Dr. Phillips:  Right so like you said, it’s definitely a case by case basis. But I can certainly comment on what we’re doing in our transplant program. So, transplant generally is for aggressive blood cancers so unfortunately, we can’t delay. So, certainly for patients who need transplants, they are absolutely getting them. We are making sure that we test them for COVID before we test them, we also test their donors. If they were to test COVID positive, we have again, in our tumor boards, and multidisciplinary expert meetings, we discuss the risks and benefits of proceeding with treatment during this time. We weigh the risks of their blood cancer progressing, what maybe alternative options they have to kind of what we call palliate their disease in the interim and perhaps consider delaying the transplant a week or two. But certainly if it’s something they absolutely need; they are going to get it.

I know for some other blood cancers; you treat obviously a lot of lymphomas. There’s been discussion about maybe if an oral regimen is possible for patients considering oral therapy over infusional inpatient therapy. I also treat some aggressive T-cell lymphoma where maybe we would be giving EPOC in the hospital and I know I’ve at least switched three patients to CHOPS so they weren’t coming in and so far, I haven’t noticed any changes in outcomes, but this is something that we’re going to be prospectively studying going forward.

Host:  Yes, I think in my experience, it’s really a range of potential ways of approaching this and dealing with this. I think that there are some patients who have been on kind of maintenance therapies where we’ve said you know it’s okay to take a pause or to delay things. You’re doing well. And we can take a break and there’s not a lot of downside in some cases to saying we can pause your therapy and resume it when things are a little quieter. On the other hand, I can say very clearly that we on a weekly and daily basis, have new patients still coming in, newly diagnosed who are able to get their scans, are able to get all their tests to see the team to get started on treatment and we’ve in the last week or two, even have been very able to start patients on therapy who need it. So, I think people should feel confident that there is some data that delayed diagnosis or delayed treatment of cancer can be an unfavorable sign meaning that patients who delay things too long may not do as well. There is a lot behind that. And so that’s I think a good reason to be sure and if you do need treatment, and your doctor says you really need to get going; that you can do that safely. Because you don’t want to cause another problem. You don’t want fear of COVID to interfere with your ability to get treatment and have a good outcome.

I would also add there’s some nice benefits. It’s sometimes easier to get an appointment now. The doctors have tended to run on time a little bit more than normal. And I think that’s an added benefit to not delaying things but really getting things taken care of.

Dr. Phillips:  I was just going to add that if a cancer patient was to get COVID and certainly I’ve treated in the last few weeks a few bone marrow transplant patients that have come down with COVID, I do have to say that we’ve been able to manage them effectively and although cancer patients, bone marrow transplant patients may be at higher risk for getting COVID, I have successfully discharged a number of COVID positive patients that are now recovering at home and we are seeing okay outcomes. So, I also just wanted to add that treatment for COVID is still even though there’s no approved option, we are getting patients through their illness.

Host:  Yeah, I would also add that important aspect of cancer care is multidisciplinary and having a team of physicians and specialists who can deal with all of this. We have at our center, as you know very routine access and involvement of infection disease experts and other professionals that can deal with different dimensions should they be needed, and most people don’t need that. But if you are in the middle of treatment and need a specialist in infectious disease complications, you certainly want that available and you also want access to clinical trials not only for cancer but for other issues that may crop up in the course of things and so, that’s a good reason to consider a center that has all of those as part of what they bring to the table in multidisciplinary care as we do at Weill Cornell.

This is an anxious time for everyone. It’s hard to watch the news or read the newspaper and hear about all of this that’s going on. A lot of questions. What advice do you give patients to try to ease their anxiety or at least get good information so that they are a little less anxious about all of this?

Dr. Phillips:  Right so, many people are not going to work or not keeping their daily schedule that was what they were doing pre-COVID, but I think during this time, it’s important to keep some kind of schedule and like we mentioned before, get good rest and exercise, eat well. But there are a number of different webinars and support groups and the advocacy organizations that have outreached during this time that I might refer patients to if they have specific needs. But for the most part, I again tell people to keep a daily schedule, get up, change their clothes, get some exercise, eat well. It’s also very important to just keep connected with friends and family because in this time of social distancing, when we’re telling people to isolate; I had a patient the other day who had a Zoom session with some of her family members that really decreased her anxiety and improved her moods. So, I would say however you are able to maintain connection with your friends, your family is something that will help you through these trying times.

Host:  So before we wrap up I want to ask you about another dimension of your work and your interest that also I think touches on COVID and that is really your expertise and commitment in reducing disparities for underserved and minority populations and I know you’ve done a lot of work in this area and have interest in this both for clinical care and research. And clearly, there’s a lot of evidence that patients from underserved populations dealing with cancer may have less favorable outcomes for a variety of reasons and that also seems to be the case through some recent reports with patients from those populations dealing with COVID. So, can you tell us a little bit about that aspect of things, why that occurs and what you see as potential solutions or at least ways that we can improve things for people who may not have the same access to care or at higher risk of developing complications.

Dr. Phillips:  Right. So, as an African American Hematologist and Oncologist, I’m particularly interested in this and you know that I’ve study a T-cell lymphoma that’s disproportionately represented among Caribbean Americans and I’ve look at health disparities and other blood cancers, lymphoma, myeloma and unfortunately, what we’re seeing with COVID is not so different to what we see with other conditions. So, preliminary data shows that African Americans have one of the highest infection rates and death rates particularly here in New York City and I think the trends are evolving in other urban areas for example New Orleans.

So, I think we’re going to continue to see data that unfortunately shows that people of color, people of lower socioeconomic status are unfortunately going to have poorer outcomes with this disease. And it’s very complex. Whether it’s a social determinant of health related to access of care, environmental related to living environments and perhaps people of color are lower socioeconomic status not being able to isolate. There are many factors whether there’s a biology to it that might predispose patients. There’s some I think data about ACE 2 the angiotensin converting enzyme 2 which is the receptor for COVID and there might be some different expression levels of that based on race or ethnicity. I think it’s a very complicated association but hopefully this is alerting our society that healthcare disparities have been in our past, they are in our present and this COVID epidemic will hopefully help change our future and address them better so everyone has better outcomes.

Host:  Well I know this area has been one that various research groups within Weill Cornell have been interested in and as we particularly look at our efforts to deliver care to patients across the city, and different communities, it’s something that is obviously a very, very important issue and I want to thank you for your efforts in raising awareness around this and I know that not only in your personal care for patients, but also your research in trying to bring transplant and other new therapies to people dealing with these challenges has really made a big impact. So, I want to thank you very much for your efforts in that regard.

Dr. Phillips:  Thank you.

Host:  Well this has been really a great discussion and I want to thank you Dr. Adrienne Phillips for your perspectives on how patients can effectively get cancer care and proceed with their treatment and have good outcomes even as we may have to at least think about COVID in the course of things and I want to encourage our patients that despite these challenges, the cancer care community is really there for you, available to help you through this and help our patients get the best outcomes that we possibly can even when we have one more challenge to deal with. So, we’re here and we’ll continue to work and move forward.

I want to thank our audience for joining us for this session. And I want to invite you to download, subscribe, rate and review CancerCast on Apple Podcasts, Google Play Music or online at www.weillcornell.org. We also encourage you to write to us at cancercast@med.cornell.edu with questions, comments and topics you’d like to see us cover more in depth in the future. That’s it for CancerCast, Conversations About New Developments in Medicine, Cancer Care and Research. I’m Dr. John Leonard. Thanks for tuning in.