Navigating COVID-19 Challenges to Provide Optimal Cancer Care

Gilberto Lopes, MD, associate director of Global Oncology at Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine

Gilberto Lopes, MD

To continue to provide optimal care to patients with cancer through the COVID-19 pandemic, the risks must be weighed with the benefits when determining whether to continue to the next step in the treatment journey for each patient or to alter the course, according to Gilberto De Lima Lopes, MD.

Adequately navigating among these challenges requires a careful balance. Although it is probably safe to postpone CT scans for surveillance, Lopes said that he does not typically delay adjuvant treatment or any treatment that can significantly impact patient survival. He also tries to continue to deliver systemic treatments. However, it is important to remember that patients with cancer can experience complications if they develop infection with COVID-19, and so close and careful monitoring of these patients is a necessity, according to Lopes.

“Cancer doesn't stop being active just because [we’re in the middle of a pandemic]. We have to evaluate each patient's case to decide whether it is safe to postpone things like CT scans for surveillance versus stopping treatment that can make an impact on a patient's survival,” stressed Lopes. “Patients with lung cancer and metastatic disease progress fast, and if we miss the opportunity to treat their disease, patients might survive for just a few months rather than years.”

In an interview with OncLive, Lopes, associate professor of clinical oncology and associate director of global oncology in the Sylvester Cancer Center of the University of Miami Health System, discussed the impact of COVID-19 on his practice and how he is coping with the changes caused by the pandemic.

OncLive: How is your institution taking precaution against COVID-19?

Lopes: This has been a very dynamic process and we have gone through several iterations of our plans. Obviously, things have moved rather quickly. We started by screening our visits and determining which patients could be seen by telemedicine and which needed to come to the institution for care. We started by screening patients for symptoms, and we're now testing every patient who has come into our institutions before proceeding with any new treatments.

We have also cohorted our patients separately. We are lucky to have 2 different buildings. Our patients with COVID-19 are currently on what we call UHealth Tower, which is our main inpatient area. Patients who require standard non—COVID-19–related treatments for their cancer and still need inpatient admission are coming to our University of Miami hospital clinic. We have 2 separate institutions, 2 separate buildings, where we can ensure that our patients with cancer are kept away from the patients who are being treated for COVID-19.

Are you experiencing any personal protective equipment shortages at your institution?

Luckily, we're not. Both our county and university hospital had enough stockpiles [of supplies] and they have been able to secure their shipments as things move forward. Furthermore, the social distancing that Miami-Dade County has very quickly implemented has helped us keep the numbers relatively small.

Miami was in the news for a while due to the teenagers celebrating spring break on Miami beaches. Did these events have any impact on the COVID-19 situation in Miami?

Luckily, the spring breakers who were on national news were not on Miami Beach; they were on beaches a little bit north of us. Miami Beach leadership and Miami-Dade County leadership moved rather quickly and closed the beaches before the state even began to think about it.

In your practice, how are you differentiating between patients presenting with symptoms associated with lung cancer versus those associated with COVID-19?

That's definitely one of the biggest challenges we are facing right now because dry cough and pulmonary infiltrates are seen with lung cancer that is progressing as interstitial spread. Patients on immunotherapy might experience pneumonitis and those on TKIs sometimes present with a pneumonitis-like picture. If we perform testing and it comes back positive, we know it's COVID-19. If testing comes back negative, unfortunately because of the high rates of false negatives, we still don't know for sure, so we're treating everyone as if they were infected. Anyone who has any signs and symptoms that suggest they could have COVID-19 are cohorted in a different hospital. We have specific units within that hospital where patients will be isolated and we’ll have all [the appropriate] precautionary [measures] in place [for not just droplets, but also respiratory]. Everybody goes in with full protective gear, including coverings over the eyes, N95 masks, gowns, and so on.

How is COVID-19 specifically impacting patients with lung cancer?

We’re seeing several potential implications of and complications from COVID-19. We will know more [about this soon], as there is a large effort being made in the form of a registry study called TERAVOLT, which is being led by Leora Horn, MD, MSc, of Vanderbilt-Ingram Cancer Center, and other colleagues. The results [from this effort] will hopefully help guide us in how to treat patients with lung cancer, specifically.

We also have a larger effort for patients with cancer in general, including solid tumors and hematologic malignancies; this is the COVID-19 and Cancer Consortium; I'm one of the members of the steering committee for that. We are hoping to have some data out within the next few weeks that may help [help us better understand] which patients are at highest risk. Moving forward, [we hope] to have more information on how to proceed [with the care of these patients].

How are you altering practice and treatment for your patients in light of the pandemic?

It is a brave new world and I'm hoping that [many of these efforts] will continue as we move forward. For example, I have not been doing my usual clinic. Instead, we have been doing telemedicine visits. Of course, if there's a patient who needs to be seen, we will arrange for those patients to come to our institutions. We have not delayed treatments for patients on adjuvant treatment, or treatments that can make an impact on survival in a significant way. We have continued to do those systemic treatments. Of course, you must be very cognizant that patients can experience complications if they develop COVID-19, so we're monitoring them very carefully.

Are you approaching immunotherapy differently in light of the situation?

We're definitely testing every patient, even without symptoms for COVID-19, by reverse transcription polymerase chain reaction [before we proceed with treatment]. We hope to soon also be able to test by IgG and IgM for COVID-19.

Are you experiencing any delays in receiving the results of CT scans or biopsies?

We are not. We have moved on to postpone surveillance scans. If anything, it's become easier for us to do biopsies and scans for those patients who actually require them.

How is COVID-19 impacting clinical trials?

COVID-19 is having a huge impact in clinical trials. At our institution, we have stopped taking on new trials, but we have tried our best to continue those patients who are on trial so that they can still receive the therapies that are making a difference. In particular, we are using telemedicine visits for those clinical trials that are treating patients with oral medications. Patients can go to one of our [local sites] or we can arrange for patients to have blood tests done at home. We do telemedicine visits so that we can continue monitoring on trial. Most sponsors have been very active and helpful in accepting this as the new standard. We have tried our best to keep those patients on trial. We have continued to enroll for trials that are ongoing, but we have not started any new studies.

Are you staying in communication with other doctors around the world? How does the situation at your institution compare with others?

We have stayed in touch with colleagues and friends from not just the United States, but around the world. In the beginning, we took a lot of leadership from colleagues in Italy and Spain, as they were ahead of us in the curve. We have tried to keep each other abreast of what's going on and help each other prepare, as the COVID-19 pandemic is behaving in waves in different places at different times.

Are any research efforts being made with regard to COVID-19 prevention or treatment that you wanted to highlight?

We are all very interested in being able to develop IgG and IgM serology tests and we're hoping to have vaccines available as soon as possible. It's very encouraging that some of the vaccine efforts are already ongoing. In terms of treatments, hundreds of drugs are either being repurposed or are being developed specifically for COVID-19 [and associated complications]. We hope that in the next few months, we're going to have more options for our patients.

It was announced that ASCO will be hosting their annual meeting virtually. How will this impact your experience with the conference?

Being at the ASCO Annual Meeting in Chicago, Illinois, is really the highlight of our year, not just because of the scientific presentations that are delivered, but also in that we are able to see in people whom we have been in touch with electronically all year long, in real life. It is a shame that we won't be able to do that this year, but the virtual meeting will allow us to continue to receive updates on scientific developments that are important for us in terms of providing our patients with lung cancer and other malignancies [with the best care possible]. A number of interesting [trials] will be coming along, with immunotherapies and targeted therapies. We are very much looking forward to seeing the virtual ASCO meeting this year.

You mentioned earlier that there are certain efforts being made right now that you hope will continue after the pandemic. Could you expand on that a little bit?

We’re probably going to continue 2 things [following] the COVID-19 pandemic experience. One of them is telemedicine. I'm hoping to be able to continue doing visits at a distance for patients who usually drive 2 to 3 hours to come see me. I'm also hoping that our virtual meetings will become more interactive and we'll be able to do more meetings without having to be physically present. That being said, we should definitely continue to have a number of meetings [in person as well, following this pandemic] because nothing yet substitutes for actually being in the same place as your colleagues and friends that you work with all year.

How can people support health care professionals and patients with cancer during this pandemic?

Stay at home and continue to practice social distancing. We really should be calling this physical distancing, because you should still maintain contact with others and continue to have a social life through FaceTime, WhatsApp, or whatever app you can use. The most important thing that people can do is to stay at home.