S1E2 | Cancer treatment and COVID-19: How are cancer hospitals keeping patients safe?
S1E2 | Cancer treatment and COVID-19: How are cancer hospitals keeping patients safe?
Jeffrey A. Metts, MD, MPHChief of Medicine, CTCA Atlanta
Dr. Pat Basu: Hi, I'm Dr. Pat Basu, the host of Focus on Cancer, a show where we answer the questions that cancer patients have about any aspect of their care. On today's show, I'm particularly excited to welcome a colleague of mine, Dr. Jeffrey Metts. Dr. Metts is the Chief of Medicine at the Georgia Hospital for Cancer Treatment Centers of America. He is also the national leader of the COVID- 19 prevention task force. Welcome, Dr. Metts. It's a pleasure to have you on the show today.
Dr. Jeffrey Metts: Thank you, Dr. Basu. On behalf of my team and I, it's an absolute privilege to be here with you today.
Dr. Pat Basu: Well, thank you. Let's get right into it by acknowledging it's been a incredibly trying time for us as a nation and as a society. On top of the COVID pandemic, clearly there's been massive unrest spurred by the tragic and horrific death of Mr. George Floyd a few weeks ago. It has really brought to the forefront, the incredible challenges and the massive progress that we need to make as a society in terms of stopping institutional injustice and eliminating racism and reducing abuse of power. It's a really important and critical time in our nation and certainly, we're all looking for a better, more perfect union. One of the staples to that is obviously, goes back to our founding fathers, the ability to peacefully protest. It's been with us for a couple hundred years, and so we stand by that right. As we've seen these protests, rightfully so from a peaceful perspective, it's brought a lot of people together in closed spaces. And so, although clearly the right to protest and the cause might be just, I'd like to get your thoughts on what that impact might be in terms of the lack of social distancing and could it be dangerous in terms of COVID- 19.
Dr. Jeffrey Metts: Yeah. People are going to do what's right. They're going to stand up against racism and against injustice. And at the same time, as we move through the pandemic, we're in a phase where there's alert fatigue. People in the country have been on high alert for a prolonged period of time and as people are social, that's very difficult. So we're seeing these relaxations across the nation on social distancing and large gatherings are happening, both protests as well as socially. So the challenge remains to keep our focus on social distancing, even in the face of standing up. And so I think that when patients and people aren't able to socially distance, or they're unwilling to socially distance, the mask becomes our best defense against COVID. COVID sees all of these people coming together as an opportunity, an opportunity to spread disease among them. Now, as evidenced in D. C. where several members of the National Guard were actually infected with COVID. So I think as we look at the number of deaths that we're currently sitting at, about 115, 000 heading to 116,000 in the country, and the possibility of going up another a hundred thousand lives lost in our country by September, by some estimates, we have to take social distancing and masking very seriously to be effective. Well, I love that perspective. I love your perspective that people are going to do what's right. But it sounds like you're saying absolutely do what's right. But you can do so still in a safe manner. You can do so, but wearing a mask and maintaining some of the precautions that prevent this. Along those lines what we've seen, not only the protests against racism and injustice, not only here in the United States, but we've now seen them across the world from London and Paris to Berlin, to other places. Talk to us about... There's been a wide variety in terms of the incidence and prevalence of COVID- 19 across not only the states in the United States but across the world. What drives that? Are there any takeaways or trends that you might comment on? Yeah, I think one of the things that comes to mind is the testing. Countries that are testing more patients... Actually, if you look at it, Denmark, I think is testing about 130 people for every 1, 000 people they have in their population. Italy is probably about 70. United States and New Zealand are in the sixties. Look at a place like India. They have 1. 3 billion people living in the country as does China. India is testing currently about four in every 1, 000 people that are in the population in their country. I guess the concern is on the early side, there were significant lockdowns that were thought to be pretty effective. It might have delayed where they are in their process versus us and what we see here. So I think it's something that we're going to have to follow closely and certainly, it's concerning.
Dr. Pat Basu: Dr. Metts, back here at home in terms of the progression in COVID- 19, are you seeing certain areas that might be coming down in terms of their COVID-19 prevalence and others that might be rising? Can you give a general overview of how it looks here in June across the U. S.?
Dr. Jeffrey Metts: Yeah, well, particularly after... We've had some relaxation socially from a social distancing standpoint and over the holiday weekend, and with the gatherings that we're having from protesting and such, we're watching very closely to see how many states are going to have an increase. And there's evidence to suggest that maybe over half are already starting to see those signs. So some states may actually have to slow down some of the relaxing measures. Very concerning. Something that we're following closely every day. We like to look at the 14- day average that gives you the data that's been teased out so it's more accurate versus, data that's coming in over only the last several days. So that's a key part of the analysis.
Dr. Pat Basu: Well, Dr. Metts, one of the things that I'm very passionate about and I've been speaking a lot about is something that I refer to called the shadow curve. And it, first of all, acknowledges that COVID- 19 is a horrible pandemic here, that's affecting us this year, but it really emphasizes not losing sight of the fact that there are monstrous diseases out there that we cannot turn our backs on. Certainly cancer, certainly cardiac disease, stroke and other major chronic diseases that kill millions of people. In fact, around the world, every single year, 10 million people will die of cancer every year. And just here in America, every single year, 1. 7, 1. 8 million Americans will be diagnosed with this horrible disease of cancer. But what concerns me is this idea. I call the shadow curve, which is we're focused only on the curve, so to speak of COVID, but as a society, as a public health system, we could be losing sight of this monstrous enemy in this case cancer or heart disease. And some of the evidence around that was recently published in the last few weeks, that mammograms were down almost 90% during the COVID pandemic. Colonoscopies were down 90%. Pap smears were down 80%. Prostate screening was down 60%. And we saw nearly a 50% reduction in cancer diagnoses, in cardiac and other neurological conditions. You and I, as physicians, as experts in public health, we know that those diseases are not going away. They're just not being caught. And when they don't get caught, they either kill more patients or they make our lives worse off. What I'm trying to prevent is the study being written three years from now that looks back and says, boy, millions of people around the world died because their care was disrupted and tens of millions had a worse outcome or a worse quality of life because we didn't get to their heart disease in time. We didn't catch their cancer in stage one. We caught it in stage three. What are your thoughts? Do you agree with me that this shadow curve might be an area of concern if we don't pay attention to all these missed cancer diagnoses and missed screenings and other conditions?
Dr. Jeffrey Metts: Yeah. I couldn't agree with you more, actually. Screening is essential to detect disease early. That gives us more treatment options. And just to your point, when you catch it later, your options decrease. I really think it's essential for cancer patients to get the diagnosis as early as possible so they can make these challenging decisions on what's the best for their care. I think it's important that the patients with heart disease are getting diagnosed. I think we have a real significant problem that doesn't capture the attention right now, because like you said, COVID's getting the attention. So as a medical community, it's really on us to raise that awareness and have those conversations so that people don't miss their mammogram. We have to challenge them to stay focused on what's right in front of them. That has to be done.
Dr. Pat Basu: Yeah. Dr. Metts. I was just talking to a colleague at another hospital. He had a patient that just before the COVID pandemic had had some screening tests done. It turns out that those indicated cancer. The patient didn't get the followup. Very recently came back and in his medical opinion had this patient's cancer been treated three months ago, instead of the therapy that they're about to go through now, the treatment would have been faster, more straight forward and with a greater probability of survival, than the course of therapy that the patient's about to go through. Do you worry that we might start seeing more of those cases that were disrupted or delayed? For you and I, the bedrock of cancer therapy has always been catch it early, treat it consistently and treat it comprehensively. Are you worried that around the country that if this continues, we might see more of those cases where we look back and say, boy, we should have caught those a couple of months ago, and now this patient's behind the eight ball?
Dr. Jeffrey Metts: I really am. I think it speaks volumes that we're having the conversation that you're raising awareness of the topic. We have to take this topic out on a larger level and raise the awareness across the country. So that's a key part of getting those screening programs back fully functional, just like we've got... Elective surgeries are rolling back out across the country. We've got to be able to do the same thing with screening. We need to make it happen as quickly as possible. Failure to do so will make those numbers astronomical.
Dr. Pat Basu: I appreciate you sharing that. And along those lines, I think one of the main topics that I wanted to get into with you, Dr. Metts is what are cancer centers like CTCA doing to protect patients and visitors and staff from the spread of COVID?
Dr. Jeffrey Metts: So again, with the concept that we know we have asymptomatic disease, we have sustained community spread and that cancer and COVID don't mix well together. Cancer centers are trying to keep COVID out and away from cancer patients. We do this with robust screening. It starts on the telephone before a patient ever shows up. Patients that have evidence of COVID. Patients that are inaudible infections should not be in a cancer center right now. Employees that work in cancer centers that have evidence of infection should not be in a cancer center right now. So it starts by having this type of screening. We then have a single point of entry for patients when they come to the cancer center. So they are screened again. Our screening again is redundant screening. That includes temperature checks when they come into that single point of entry. We use universal masking. So that any patient that shows up, any employee that's on center should have, and will have a mask. If they don't have one, we provide the mask for them so that we can really provide the safest environment possible. Our employees that can work remote, we have initiated a very comprehensive remote working from home approach to try to thin out the number of people that are in the center at any one time. We've decreased the number of visitors. We've eliminated non- essential travel for all of our employees. So it's really about providing the safest environment possible. The other thing that we've done is rapid turnaround time testing, using several different testing strategies, but we're able to get quick results. Sometimes patients have cancer and that cancer can mimic COVID. It might be that it's a metastatic process to the lung. It could be that they are under chemotherapy or immunotherapy that can mimic fever and shortness of breath. Basically inflammation processes going on in the lung. So for us to have rapid testing we can identify them quickly and get to the accurate diagnosis and initiate appropriate treatment strategies for them. We also use our rapid testing for all of our patients prior to surgery. If anyone's undergoing an aerosol- generating procedure, we test them in advance to make certain that we don't have anybody that is COVID positive go forward with the surgery until they're COVID negative.
Dr. Pat Basu: Well, Dr. Metts that's very helpful. Sounds like you're doing a ton to ensure that separation and that safety. Let's talk a bit more specifically about rapid testing. Sounds like that's one of the keys you described. First of all, can you describe for our listeners, how rapid is the test? What does it entail? How quickly do the results come back?
Dr. Jeffrey Metts: So if you look to the early periods of COVID, the testing would take anywhere from one day to eight days. During that time, anybody that's been tested, you have to assume that they have COVID. You have to treat them as if they do. That means you use a significant amount of personal protective equipment, PPE to provide that safe environment. So when you have five, six, seven, eight, 10 patients that are under investigation, your PPE burn rate goes up significantly. If you can get a rapid test and for us, the test we use takes about an hour. It really takes about 15 minutes, but the turnaround time. Transportation, collection of the sample, all those things. Within an hour, we have an answer. And so, one, you eliminate all of the PPE. Two, you make the correct diagnosis, and then you can initiate appropriate treatment strategies for the patient. So much of the success for COVID is about identification, isolation, contact tracing, testing. So by being able to do all of those things, it puts you in a more successful position. I also like to look at our surgical patients. Patients that are about to have surgery, who are having major surgery, they get tested. If they were positive, and they would go through their surgery, it puts the patient at risk for disease progression. It puts all of the staff at risk to contact and/or spread the disease. Even though they're taking maximal amounts of safety implications already, it adds that extra layer. And we find our patients really appreciate it. Now to collect the test, it's a nasal swab. It's done very distally, right to the edge of the nose. And then you get the sample and you're able to send that in. And like I said, you have the results in less than an hour. There's also other testing that goes much deeper. Nasopharyngeal into the nasopharyngeal cavity to collect the sample. A little bit more aggressive for patients. You asked about how they compare. We've done them both, and we've found them to be equally effective.
Dr. Pat Basu: Well, that's terrific. And it sounds like, between some of those pillars you described, it's been a very sophisticated, very robust method of protecting patients. Tell us a bit if you look back now over the last few months, how successful have you and the team been at preventing COVID at our hospitals and ensuring it's the safest possible environment for treating cancer that there possibly can be?
Dr. Jeffrey Metts: If you think about academic institutions and you think about community centers, which provide outstanding, excellent care, and they have safety strategies. We're taking care of COVID patients. We're taking care of COPD, lung disease, heart disease, diabetes, trauma. In a cancer center we're focused solely on cancer and so to your point keeping COVID out is the core strategy. The rapid turnaround testing helps. It's a significant part of it. The screening, the universal masking, decreasing the number of visitors, decreasing the number of people, social distancing within the center, including the waiting rooms, the common areas, our dining center. Every area where you can make an impact gets looked at and addressed. Going back to our patients that we test for surgery. We've caught several in advance and been able to postpone their surgery to a safer time. You might think that some of the patients would see all of this as a little bit of an inconvenience, but we've actually found just the opposite. Our patients are very appreciative when they see all these layers of safety that they're following and so it makes a big difference to them. They feel safer and our staff feel safer.
Dr. Pat Basu: That's terrific. I know that's going to be great for patients to hear. What should they expect Dr. Metts when they arrive at a CTCA facility? Can you walk them through start to finish maybe what that looks like in terms of the screening process and how it's different than what they're used to in a pre- COVID world?
Dr. Jeffrey Metts: So the screening process for them starts again by telephone before they ever leave to come over to CTCA. So we have to be very cognizant that we give them appropriate instruction and direction. Are they appropriate to travel? Are they going to the closest cancer center? Are they following optimal safety precautions while they're traveling? Once they arrive, then they enter a single point of entry. We have them walkthrough, they go through a series of questions, and they have their temperature checked. And if they don't have a mask already, we then provide a mask for them. And then they start their day. They go to their appointments. They see their medical oncologist. They see their radiation oncologist. They see their surgeon. They see the support teams that they've come to know well and work with.
Dr. Pat Basu: And can you mention specifically, have you made any changes to how many visitors they can have accompany them or any other precautions with respect to patient visitors?
Dr. Jeffrey Metts: Yeah, so we allow one caregiver per patient, and this will probably be in effect for some time as will the universal masking as will the screening for some time. While we're pursuing a vaccine across the country, once we get to that point, things might start to look different, but for the foreseeable future, their routine is going to be again screening, universal masking and then decrease in the number of people that are in the center that includes single visitors. For our surgical patients, postoperatively we're rapidly looking to get to a position where they're able to have visitors again. And so in the early going, we could not have patients up on the general, surgical and medical floors. This is something, again, that is important to patients, and we've heard them, but at the same time, they understand that safety for them and those around them is the most important approach that we can take.
Dr. Pat Basu: You mentioned universal masking there. Can you describe a couple of things? Number one, how are you doing at the hospital in terms of having enough masks? And then I want to get into some other questions related to what types of masks or when patients should have those on, but let's start with how are you doing in terms of the adequate amount of masks and other PPE?
Dr. Jeffrey Metts: So in the very beginning, as we were watching the pandemic spread across Italy and Spain before it came here, we gathered our materials management team. We gathered our infection control teams. We came together. We scoured the literature to really understand what PPE conservation is. A term we hadn't really had to talk about too much in years past. All of us in the healthcare industry have the same challenges of as far as getting access to PPE gear and getting masking. So we came up with the latest calculations on how to understand how much we'll need depending on if you have a patient that's under investigation or a patient that would be positive. And also how many encounters are going to happen in a patient's room. How many visitors, I should say how many healthcare professionals or visitors are going to go into a patient's room? So all of those things had to be factored in. We didn't know how to secure the PPE that we needed and put ourselves in a position where we would not have any interruption. We also had to look at the PPE conservation. Good example is the N95 mask. More in demand than the surgical mask. Surgical masks are much easier to come by than the N95 masks. So we found ways that we could utilize an N95 mask for an entire day, by covering them with surgical masks. And then replacing the surgical mask as we go through the day. So that's made a significant impact on our ability to obtain PPE and then go ahead and preserve PPE.
Dr. Pat Basu: That's very helpful. And Dr. Metts at a larger level that there was some controversy or maybe debate at some point earlier in this process of whether people should be wearing masks in public. Some well- known figures showing up in public places or hospitals without masks. What's your general guidance to, first of all, it's called the American public in terms of, should they be wearing masks when they go in public places, when they go grocery shopping, what's your suggestion there as not only a cancer care expert but also an expert in the prevention of COVID- 19?
Dr. Jeffrey Metts: Early on we adopted the universal masking policy. We were strong advocates for it, even before we sold out across the medical community. So much so we actually had artisans craft and send masks over when the surgical masks were in demand. Once the surgical masks became more readily available, this is what we use in our patient encounters, but the artisan masks in the general public have a high value. I think the brightest minds that we have in the medical community have agreed that social distancing is the first thing. And then masking is the second component. Obviously, robust testing and contact tracing strategies and isolation are all important parts of being affected against COVID. But I think it's now generally accepted in the medical community, widely that universal masking is a key part of our success and our strategy for being successful.
Dr. Pat Basu: So to our listeners, would you suggest that if they're... As we enter various phases around the country of opening up, whether it be restaurants or stores, would you recommend that in general, if they're in a public place that they do have a mask on?
Dr. Jeffrey Metts: Absolutely. And again, I would still recommend social distancing. That should be the first thing that they think of when they start planning what their social events are. We know it's healthy to get outside. People need to get outside. That's good for mind and body. At the same time, social distancing is key. And then masking when they're in any of those environments. Really it's about the maximum effect of safety that we can provide them.
Dr. Pat Basu: What have you learned in terms of treatment of COVID? What's showing promising signs of halting progression or improving survival versus what might we have learned about some things that have not worked?
Dr. Jeffrey Metts: First with medications, initially we'd hoped that hydroxychloroquine might be an option, but that has since been proven not to be effective. And currently the only drug that has shown success in clinical trials is Remdesivir So from a drug standpoint, that's obviously in demand. That's being used. But I think what we're also learning is a different approach to taking care of patients. The intensivists who are really on the forefront of treating COVID patients traditionally, they would use mechanical ventilation early when there was failure in the lungs, and they would give lots of fluids. And what they've learned with COVID is that we try to pursue high oxygen states, high flow rates first, and we keep the lungs very dry. The problem with keeping the lungs dry is that the kidneys, they like fluid. And so there's a balance they have to maintain. So it can be very challenging for the intensivists and certainly, we are all incredible fans and appreciative of them and all of their efforts.
Dr. Pat Basu: No question about that, Dr. Metts. Well, as I mentioned before, I'd like to transition specifically to some of these patient questions and maybe as a segue into what you just talked about in terms of therapies and prevention. There's a couple of questions here from patients that I think actually blend in pretty well to what you just spoke about. So the first is from a patient who asks, I'm taking immunotherapy to treat my cancer. Does that mean that my immune system is stronger and thus I'm less likely to get COVID- 19?
Dr. Jeffrey Metts: Unfortunately, it does not. Certain types of cancer, they attack the immune system, and they turn a switch to deactivate our ability to fight cancer. So immunotherapy is often geared towards deactivating the cancer's ability to deactivate the switch so that we can then attack the cancer. At the same time, immunotherapy can have a lot of complications and side effects. A lot of inflammation, inflammation of the lungs, inflammation of the gut. It unfortunately does not prevent COVID. It does not treat COVID, but it's a very thoughtful question.
Dr. Pat Basu: It is. And something somewhat in a similar vein, a patient sent in this question. I have bladder cancer and I've received BCG as a part of my therapy. To what extent will that prevent me from getting COVID- 19?
Dr. Jeffrey Metts: There are a couple of trials that are underway exploring that, but to date, we have not seen any evidence that BCG vaccine often used for tuberculosis is effective at preventing COVID.
Dr. Pat Basu: Some other really good questions from patients here. This one that actually has to do with telehealth. The patient asks that I know you've been offering some appointments via video conference and technology, and now that followup appointments can be done in person, will you continue to offer telehealth visits?
Dr. Jeffrey Metts: We haven't talked about telehealth. It's actually one of the best PPE barriers that exists. Telehealth's here to stay. It allows us to optimize the patient visit when patients are here. Some visits require treatment and other visits are followup. So we can really optimize some of those follow- up visits and really focus the visits that need to be in person on treatment. Telehealth is also going to have a tremendous impact in the community. All of these rural areas, where it's difficult to get access to healthcare, where patients are facing diabetes and heart failure, high blood pressure, and obesity. All of these things that contribute to shortening the life causing hospitalizations and things of that nature, telehealth can help us get access earlier and decrease the impact that those diseases have on patients. So I think as a nation we're going to see telehealth here for a long time.
Dr. Pat Basu: That's terrific. And are there any things that you foresee that have happened or might happen in terms of the regulatory environment that might enable telehealth to be even more prevalent and useful going forward?
Dr. Jeffrey Metts: Yes. A significant relaxation in a lot of the regulations. It proves that when we're faced with an imminent danger, we move quickly. We have providers that can practice in- between state lines now. We know we have the technology. We know we have the ability and now we know we actually can cut through the red tape and make it happen. So it's a lesson that we all need to take and it's what patients need to demand. They should demand that they have access to healthcare, and this is a way to get them that access long term.
Dr. Pat Basu: Fantastic. A couple more patient questions I wanted to make sure I got to here. This patient asked, I am participating in a clinical trial, but I'm not able to travel to my next scheduled appointment. What should I do?
Dr. Jeffrey Metts: So each question like this has to be taken on a case by case basis. I would highly recommend that the patient contact their cancer care treatment team so that they can work in a partnership and develop a plan that they can then follow. It's possible that they're a candidate for a telehealth visit, or it's possible that they can adjust their visits again, so they can optimize the time spent together.
Dr. Pat Basu: And finally, in terms of a direct patient question, I think I'll choose this one. As a cancer survivor is it safe to be out in public?
Dr. Jeffrey Metts: Well, first for all cancer survivors, congratulations on being a cancer survivor. You inspire patients. You inspire the medical profession. You're why we do what we do. And I would tell you, it's essential that you get outside again for health of mind and body. You have to get outside. You have to get out of your house, but you have to do responsibly. You have to socially distance and you have to use a mask. Something that cancer patients are probably a lot more familiar with is the concept of being immune- compromised and many of them have already had to do things that involve social distancing. They've had to miss important life milestones and weddings and graduations because of where they are in their fight. And many of them are alive to tell these stories now. So I think it's important that we all listen to what they're saying because as medical professionals, we can learn from them and other patients and other people out there that are learning about social distancing can also learn a lot from our cancer survivors.
Dr. Pat Basu: You and I do this because we love the care of cancer patients and this horrible disease. They are, as I'm sure you agree, some of the best strongest toughest patients in battling this disease. Can you give them some sense of what can they look forward to during this? I think it's critical for cancer patients to have hope and keep their eyes down the line in terms of the optimism and hope. Can you share a message for them that might give them some reasons to be optimistic?
Dr. Jeffrey Metts: Yeah, I think so many of them have fought cancer, and they've gone through stages where they're in an immune- compromised state and where they can't participate in that graduation or that wedding, that life milestone, and have had those disappointments. And a lot of patients that we meet, they fight cancer, so they can make it to those milestones. So as COVID comes out and takes a lot of those things away from them, it's really been on the one side they're experienced on the other side they didn't want to be more experienced. And so I think it's important that they know that we've made a tremendous amount of progress with a vaccine. We've never seen anything like it. We're used to five to 15 years for a vaccine, and we're looking at a year with multiple companies all participating and will likely have multiple vaccines. By the beginning of 2021, we could be seeing hundreds of millions of vaccines distributed. So, I hate to tell them to be patient. Instead, I'd say let's be hopeful that if we're smart right now, and we take our time, and we optimize social distancing and masking that, those milestones that we're all, so socially engaged and in tune with are going to be coming back as we enter 2021.
Dr. Pat Basu: So thank you so much for taking the time to be on the show today and share your expertise. On a personal note, I'm extremely grateful to you for everything that you've been doing to keep our patients and caregivers and employees safe, not only during the past few months of this COVID- 19 pandemic but going forward. It's been really world- class what you've done, and we're very grateful. So thank you so much and have a wonderful rest of your day.
Dr. Jeffrey Metts: Thank you for having me and on behalf of me and my entire team, we really appreciate the opportunity to serve our patients. Thank you.
Dr. Pat Basu: Please join me on the next episode where I'll welcome Darren Keller, a successful innovator and entrepreneur who will share his perspectives on advancement in cancer care and technology and other innovations that can help change the face of our battle against cancer.