• Published on Aug 21, 2020

Video Transcript

JOHN WHYTE: You're watching Coronavirus in Context. I'm Dr. John Whyte, Chief Medical Officer at WebMD. What's been the impact of COVID on cancer care? To help provide some insights, I've asked Dr. Robert Keenan, he's the Chief Medical Officer of Moffitt Cancer Center.

Dr. Keenan, thanks for joining me.

ROBERT KEENAN: Thank you for having us on.

JOHN WHYTE: Let's start off with what's happening with cancer screenings? We're hearing that patients aren't getting colonoscopies. They're not getting mammograms. They're fearful of coming in. How do we help assuage their concerns and let them know that it's safe to come back, assuming it is? So tell us the latest.

ROBERT KEENAN: Sure. So, uh, if I can go back just a couple of months to the first peak of this pandemic, obviously, nobody knew what was going to happen. And so screenings, as you mentioned, screening colonoscopy, screening mammography, um, we stopped doing those, um, for-- for several different reasons. But we spent a lot of time early on trying to make sure that what we were doing here at the center was ensuring an atmosphere of safety for patients.

So then, when that first peak started to wane and we started back, um, offering some more of those routine services, screenings became one of those services that we started to offer again. Um, and right now, in fact, the screening program that we have is operating pretty close to normal, um, to what it was even before the COVID.

And I think that that's a combination of factors. One is all the effort we put into trying to make sure that people were aware that this was safe. Uh, secondly, making sure that people were aware that cancer doesn't wait for COVID, um, and therefore, screening needs to be done, um, whenever possible. And thirdly, trying to make it, uh, possible for patients to come in and get screened in ways that minimize their interactions with other employees and other personnel within the center, so that we try to allay their fears that way as well.

JOHN WHYTE: How are you doing that? What's different now than it was pre-COVID?

ROBERT KEENAN: Well, the first thing is, of course, uh, visitor policies. We needed to institute a very strict no visitor policy. And so for those patients that needed to come here, uh, they came here on their own, and any caregivers that with-- that were with them, um, would wait in a, in a vehicle, or we set up, uh, some areas outside of the hospital, uh, that they could, uh, wait in until the patient was ready.

As we started opening back up again, of course, we wanted to take into account social distancing. And so looking at all our clinic spaces and figuring out how we could create that safe distance between chairs, uh, made a lot of difference. Um, and then, of course, thirdly, from the screening perspective, um, offering kind of different pathways for those screening individuals to come through, uh, as opposed to the patients, uh, again, minimized the extent of interactions.

JOHN WHYTE: What do you say to patients who are watching that might think, you know what? I can wait 'till next year. Let me let this all get, you know, through, and, you know, it won't be so bad if I just wait, you know, another six months. What's your answer to that? Is that an OK plan?

ROBERT KEENAN: Well, uh, clearly, the answer to that is no. Um, you know, certainly there are going to be people who, um, are getting screened and who do not have cancer now and a year from now, also will not have cancer. But of course, the reason we do the screening is because we want to try to pick up patients as early as possible, because that's when we have the best chance of cure.

Uh, and so there's a huge difference between saying, you know what? I'm due for my yearly mammogram, but I'm going to put it off for a month versus saying, I'm going to put it off for a year. That can make the difference between having a very treatable and very curable problem, uh, to having one where the disease may be much more advanced, still might potentially be curable, but the treatment strategy is going to be a lot more complex.

Um, and we're already seeing some studies in the literature that are suggesting that there could be 10,000 or 15,000 excess deaths in the United States as a result of patients not coming in for those kinds of routine screening studies.

JOHN WHYTE: What do patients do that, you know, are losing health insurance by losing their job? What are the, you know, possibilities for them to get screened?

ROBERT KEENAN: Sure, uh, and so-- so for those, uh, patients, uh, there are charity programs. We work with them, uh, to see what we can do to try to mitigate that-- that financial burden as much as possible. Uh, obviously, there are patients who may be eligible for other forms of insurance, whether it's Medicaid or for some-- some other form, and so we'll work with them. Uh, but we really want to try to minimize the number of patients who are not able to come in purely for financial reasons.

JOHN WHYTE: Let's talk about those patients who have cancer or perhaps are cancer survivors. Um, how do the, you know, public health precautions apply to those two categories, cancer survivors, that maybe are five, 10 years out, and those that are currently undergoing chemotherapy? Do-- do we apply the same standards, or do those patients that are currently undergoing chemotherapy really have to be much more vigilant? What counsel do you-- do you have for those two groups?

ROBERT KEENAN: Well, the first thing I would say is that cancer patients in general are very well attuned to the risks that they face. And so our experience at Moffitt has been that the number of cancer patients who develop COVID has been much less than in the general population. And it's because our patients, whether they're-- whether they're in active treatment or not, those patients are taking those precautions very seriously.

That's also part of the reason why we need to be able to reach out to them, and we've used the virtual health platforms, telemedicine platforms, to keep in contact with them so that we can make sure that those patients who are undergoing ongoing treatment or even just surveillance, that we are not losing track of what we need to do to make sure that their cancer is under control.

Now, in terms of the absolute risk, um, we believe that cancer patients who, uh, are not showing signs of active disease who are in that surveillance mode and even survivorship mode are not at any increased risk than the general population, assuming, uh, of course, that they may have other co-existing, um, conditions that could put them-- put them at risk. And so they-- they need to take those types of precautions that anyone would, uh, given those, uh, patients.

Patients undergoing active treatment are in a little bit different category. And we want to make sure that we keep on top of their symptoms, any symptoms that they have, because often, those symptoms, uh, which could be from their underlying disease, might also be COVID as well.

So one of the things that we've done is looked at our portfolio of chemotherapy regimens, for instance, and said, we are going to routinely test those patients to determine whether or not they might have COVID, uh, in order to make decisions as to whether we're going to continue treatment or not. Now, we've made the same sort of, um, uh, requirements for radiation therapy as well.

And even in surgery, where we find that, uh, because the risk post-operatively of developing significant complications if someone is inadvertently found to have COVID after surgery, we want to make sure that we try to identify those patients ahead of time. So we test them, and if we can delay surgery, we will.

But of course, whether it's surgery or chemotherapy, if the risk of the disease that they have far outweighs the risk of COVID, we need to proceed. And we have done that on a few occasions.

JOHN WHYTE: What are some of the changes that you expect we'll continue to see in a post-COVID world related to cancer care? So for example, we never really thought about, um, giving many chemotherapeutic agents within the home, but there's been some discussion around that.

People have been doing clinical trials in the home, whereas before, we would always say, patients need to come into the center. They need to come in to the hospital. COVID has changed some of that. Is that going to continue in a post-COVID world?

ROBERT KEENAN: You know, I hope so. You know, a lot of us kind of look at COVID as an opportunity. It's-- it's been a catalyst that's actually accelerated a lot of the changes that many people think should be happening anyway. We have had ongoing conversations with several types of partners to look at alternative sites of therapy.

Of course, the whole field of oral antineoplastics, if there's an oral option as opposed to, um, an infusion option, even if there's an injection, a subcutaneous injection you could give as opposed to, uh, you know, a 30 minute or hour long infusion, we should be considering those kinds of things.

And we have to, and-- and we are definitely pursuing those. The other.

JOHN WHYTE: Would it bee too paternalistic, saying, oh, it's too dangerous to do this in the home. We can't do it in the home. We can't do it in-- you know, unless it's a center.

ROBERT KEENAN: Well, I think that, um, we have to look at the risk benefit. And what we can say is that this is already occurring. There are some centers that are doing some of these infusions in the home. We ourselves have looked at our catalog of infusional of agents and said, which of those infusions or injections are we doing that really carry very little risk? And could we do them in an alternative site?

We would need to make sure that there's proper supervision. But we can definitely do some of those things, um, in an alternative site. And one of those alternative sites might actually be, uh, on campus. So we are starting to have some conversations around drive-through testing and-- and treatments. Someone can come in and get a subcutaneous injection, but we can do that in their car.

You mentioned the clinical trials. Uh, the virtual therapies, uh, or virtual visits, now, are-- are what is allowing us to keep tabs on patients, uh, and there's a number of the, um, pharmacy studies that are allowing virtual visits for clinical trial patients that never did before. This opens up widely the door for greater enrollment in clinical trials when someone isn't required to have to physically come back to the mothership, uh, on a regular basis.

JOHN WHYTE: I want to ask you about this editorial that talked about, it's time to remove the hurdles to cancer care, and maybe COVID is going to do that, that we need to get rid of the red tape of prior authorization and step therapy. We need to reduce out pocket costs, and we ensure cost sharing assistance to benefit patients.

You think those things will happen?

ROBERT KEENAN: I hope so, uh, and I do think that there is, um, there is some impetus, uh, across the board. Again, this is part of COVID as an opportunity. So whether it's telemedicine and the fact that now commercial insurers and CMS are allowing telemedicine visits where they weren't before or where they were restricted before opens up tremendous opportunities.

Um, we ourselves are very proud of the very comprehensive pathways that Moffitt has developed over the years. Multidisciplinary, tri-modality therapies from beginning to end, from screening, um, interum prevention, through-- through to the end. And making arguments, particularly with the commercial insurers, that by following those pathways, we are providing the most comprehensive, cost effective, highest quality care.

So if we can do that, and we say we're following our pathways, all of a sudden, that whole layer of prior authorization should go away. Because-- because we are in agreement that we are following the best road to care for those patients. All of those things need-- need to be pursued even further.

JOHN WHYTE: What do you predict cancer care will look like in five years, Dr. Keenan?

ROBERT KEENAN: Well, I think that, um, in some ways, it will look similar to-- to today but-- but maybe with some slight nuances. So on the surgical side, we're doing a lot more minimally invasive surgery, uh, than we were doing before. We're doing a lot more precision surgery than we were doing before.

And so we are in a situation where now, patients are having outpatient, uh, procedures that would have kept them in the hospital for a week or more, um, even-- even five years ago. Um, on the medical therapy side, we talked about the oral antineoplastics. The conversion of many of these, um, long term infusional therapies to subcutaneous or intramuscular injections.

We're going to see a lot more of them. Um, we're going to see the biosimilars coming along, which will give us greater, uh, greater options there. We are looking at radiation therapy and saying, you know what? It makes no sense that everybody with one particular type of cancer gets a set regimen of x number of centigrade of radiation therapies five days a week for x number of weeks. We are becoming more precise in determining what's the right level of radiation for that individual and that individual's cancer.

I see all of those things, um, being even more prominent in the next five years.

JOHN WHYTE: I don't want to get too much in the weeds, but I'm going to push you on biosimilars. There's been slow adoption of biosimilars for a variety of reasons. Why do you think all of the sudden we're going to see greater adoption?

ROBERT KEENAN: Well, I think that it's going to be forced upon us by the insurers. Um, and I think that that's OK, um, as long as we can, um, come to some agreement on-- on which biosimilars are really appropriate and which are not. The challenge that those of us on the provider side, of course, have, is that if every insurer makes their own unique decision on one particular biosimilar, it makes it very complicated, um, to-- to be able to manage that.

Whereas if we can come to the table and come to some agreement on-- on some of these biosimilars, then I think we have a real opportunity to lower the cost of care, um, and still provide the same level of quality, uh, that the-- that the name brand, uh, therapy provided.

JOHN WHYTE: And finally, I want to address the issue of disparities in cancer care. We've seen the impact of COVID-19 on people of color. You and I both know the impact of cancer in general on minority populations. People of color, especially blacks, have the highest mortality from most cancers than any other group.

What's Moffitt, and-- and what are your colleagues doing to improve cancer care for minorities and marginalized and vulnerable populations?

ROBERT KEENAN: We have had a Diversity and Inclusion Office now, uh, for-- for quite a number of years. A big focus of that is the sensitivity around how to make sure that we are trying to provide the best care for patients, uh, and recognizing the unique experiences of people with different racial and cultural backgrounds.

Just recently, uh, maybe a year or so ago now, we actually created a new Associate Center Director-- sort of the equivalent of a vise president-- position for community outreach and inclusion. Uh, that's Dr. Susan Vadaparampil. And her mandate is to make sure that Moffitt is not just in the community but it is part of the community. It is, how are we going to reach out to disadvantaged, uh, populations? Populations of color, and making sure that we are working with governmental and nongovernmental agencies to provide the access to care that they need.

It extends to some of our screening programs. We have a Mole Patrol. We've had prostate cancer screening. We have lung cancer screening. Trying to make that available to individuals who may not have insurance coverage, uh, to allow them to get screening elsewhere.

So it's extremely important, uh, that we try to not only get, uh, disadvantaged patients for clinical trials, but frankly just for standard of care, uh, and that's a big part of what-- what Susan's job is, and those of us on the clinical side working with her.

JOHN WHYTE: Well, Dr. Keenan, I want to thank you for taking the time today to-- to share your insight as to how COVID is impacting cancer care and what the future may look like.

ROBERT KEENAN: Thank you, Dr. Whyte.

JOHN WHYTE: And thank you for watching Coronavirus in Context.