Hear from Our Experts: MSK Information Session on April 23, 2020

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At Memorial Sloan Kettering, we’re committed to supporting our community and keeping everyone informed about COVID-19 and how it affects people with cancer. We held an information session with MSK experts who provided answers to some of the frequently asked questions regarding COVID-19.

Some of the topics covered include:

  • What is COVID-19?
  • What makes someone immunocompromised?
  • How long after cancer treatment are patients at a greater risk for COVID-19?
  • What is MSK doing to address the risk of COVID-19 in its clinical locations?
  • How will MSK begin resume critical cancer care procedures like surgeries?
Transcript

Cancer and COVID-19
MSK Information Session
April 23, 2020

Corporate Speakers

  • Lisa DeAngelis; Memorial Sloan Kettering Cancer Center; Physician and Chief Medical Officer
  • Tobias Hohl; Memorial Sloan Kettering Cancer Center; Chief, Infectious Diseases Service
  • Diane Reidy; Memorial Sloan Kettering Cancer Center; Oncologist
  • Jeff Drebin; Memorial Sloan Kettering Cancer Center; Chair of the Department of Surgery
  • Liz Rodriguez; Memorial Sloan Kettering Cancer Center; Director of Nursing
  • Marcia Levine; Memorial Sloan Kettering Cancer Center; Senior Director, Perioperative Nursing
  • Neil Halpern; Memorial Sloan Kettering Cancer Center; Critical Care Medicine Physician
  • Chris Nelson; Memorial Sloan Kettering Cancer Center; Chief, Psychiatry Service
  • Presentation

    Operator: Good afternoon and welcome to the Memorial Sloan Kettering Information Session for Patients and Caregivers. Our host and moderator for today’s call is Dr. Lisa DeAngelis, Physician and Chief and Chief Medical Officer at Memorial Sloan Kettering Cancer Center.

    I will now turn the call over to Dr. DeAngelis. Please go ahead.

    Lisa DeAngelis: Thank you. And welcome to this MSK Information Center Session. I’m Lisa DeAngelis, the physician and chief here at Memorial Sloan Kettering. And the topic of our call today will be COVID-19 and cancer, and how COVID-19 affects people with cancer.

    We’ve received over 1, 000 questions from all of you in advance. And we want to thank you for sending in your questions and for joining us here today. We are going to try and get to as many of those questions as we can and if there’s time, we’ll also take some questions live on this call.

    I want you to know that as always, MSK is working hard to keep you and your loved one safe when you come in for an appointment or treatment at any of our locations, and we’ll discuss in further detail exactly what precautions we are taking and will continue to take in the future.

    We know of course that many of our patients are immunocompromised, and already dealing with the challenges that a cancer diagnosis brings. We know you are feeling particularly vulnerable and have implemented rigorous efforts to make sure that your safety is assured when you come to MSK.

    Every one of us has many questions at this time. But I think cancer patients have even more because of their unique situation. So we’ll attempt to answer as many of your questions as we can.

    To start off, I’d like to invite Tobias Hohl, who is chief of our Infectious Diseases Service to give us some brief background on where this virus came from, and how it is spread. Tobias.

    Tobias Hohl: Thank you, Lisa. None of us had heard of this virus as a four months ago. The SARS-CoV-2 is a coronavirus, and it belongs to a family of viruses that spreads from animals to humans. So SARS-CoV-2 the virus that causes COVID-19 probably originated in bats. And sometime in November or December of 2019, it jumped into humans, and then began to transmit between different human beings.

    The virus enters the human lung, so its major mode of transmission from human to human is via the respiratory route through droplets. So the way the virus accomplishes this is that it has a key on its surface. That key is called the spike protein. The spike protein finds a lock within cells of the lung. And that lock and key mechanism allows the virus to enter cells in the lung. Once the virus is inside the cells, it hijacks the cells and replicates within the cell creating many, many copies from a single particle that was able to enter the lung cell.

    At the end of this replication, the lung cell is destroyed and there is much more many more particles that are released. That is why the virus is transmitted when we cough. The good news is that our body has natural defenses against this virus and self-infection fighting cells come into the lung and destroy virus particles. So that’s the basic way in which the virus is transmitted and how we combat this infection.

    Questions and Answers

    Lisa DeAngelis: Thank you. You know, Tobias we have received an overwhelming number of questions about immunocompromised patients. What makes someone immunocompromised and for how long after cancer treatment? Are patients at a greater risk for COVID-19?

    Tobias Hohl: So I know this is a question that is of particular concern for MSK patients and anyone who is facing a cancer diagnosis. So the term immunocompromised means that either the cancer or the treatment of a cancer causes some form of damage to our infection fighting system. And we are obviously concerned that some patients with cancer may be more vulnerable to COVID-19 disease compared to individuals who do not face a cancer diagnosis.

    What we do know is that we have already diagnosed and treated COVID-19 disease in over 600 patients at Memorial Sloan Kettering. So we’ve learned a lot in the last five or six weeks since we first started treating patients with COVID-19.

    The majority of cancer patients who present to the emergency room and have symptoms of COVID-19 do not need to be admitted to our hospital and can be safely managed at home and recover, even among patients who have to be hospitalized, the vast majority recover from the illness. And we have now a wide range of experimental therapies that we can offer to our cancer patients. And this is particularly relevant for those who have underlying damage to their immune system or immune compromised.

    I’ll just give you one example. We’ve been able to begin treating patients with convalescent serum that is we are transferring the infection fighting capabilities to cancer patients via this technique to help them recover from this illness.

    Lisa DeAngelis: And Tobias, we’ve heard so much in the lay press about testing, both testing for the virus and antibody testing. First, can you tell us who should be tested for COVID-19? And do we have enough test In the United States right now, and specifically an MSK right now?

    Tobias Hohl: So at MSK, we’ve been very, very fortunate to work with an outstanding group in our Laboratory Medicine Department and we developed for the Laboratory Medicine Department developed a test for COVID-19 before cases were seen in New York City. So we’ve been able to test any cancer patient who has symptoms of COVID-19 disease for the past six weeks, and that has been instrumental in allowing us to identify MSK patients with COVID-19. It’s a rapid test, we get the same day results. So that’s also very, very helpful.

    So this test detects traces of the virus. Lisa, you also mentioned antibody tests. And I know that there’s an enormous amount of interest. And New York State just released the initial results of widespread testing today.

    The antibody tests are not helpful in identifying who has disease right now, because it takes several weeks for antibodies to form after someone has COVID-19. So what we’re doing in the antibody test is we’re looking for a sign of the infection, a sign that the immune system had to come back COVID-19. It’s very helpful on the back end to tell us who was infected and who was not.

    Now, many of you have been hearing about these tests, presumably for several weeks. And one of the difficulties in terms of a national rollout has been how precise these antibody tests are. And that has been the greatest challenge so far, because in a perfect world we want an antibody test that detects COVID-19 and no other virus or other pathogen and achieving this gold standard has been the final hurdle that we have had to overcome in order to use these tests more widely.

    But to get back to the core of Lisa’s question, what I want to state is that we have the testing capacity to determine which MSK patients have COVID-19 and if you do have COVID-19, we have a terrific treatment and management plan for you and we will take care of you with great skill.

    Lisa DeAngelis: Thank you. Tobias, hang on for a minute because I’m going to turn for one minute to Diane Reidy, who is medical oncologist here at MSK and has been instrumental in helping us develop the plans for how we take care of cancer patients with COVID – who are infected by COVID-19. And Diane, could you just say a few words about the outpatient program that we’ve been able to put into place?

    Diane Reidy: Absolutely, Lisa. Yes, and as you explained, we really do care deeply about the health of our patients and for all of our patients that are listening, we hope you recognize that your safety is always at the forefront of everything that we do.

    And so given the COVID-19 crisis, we have put in place many policies and procedures to address these unique challenges brought on by this virus. So first, what we’ve done is we’re screening all patients and staff for symptoms of COVID before they enter any MSK locations.

    And so the way that that works is that your doctor’s assistant will call you about a day or two before your appointment and they’re going to ask you how you’re feeling and questions focused on symptoms of COVID-19. If you have any of those symptoms, your doctor will then arrange for testing of COVID-19. If you don’t have those symptoms, then your appointment will be confirmed.

    Now on the day of the appointment itself, when you get to the door, you’re actually greeted by a nurse. And you’ll notice that he or she is wearing a mask and does have the appropriate personal protective equipment or PPE that they’re wearing, they will again ask you the same questions and if you do have any symptoms on that day, you will be offered testing and swabbing immediately. And then after your swabs, you’ll be asked to return home until those tests results. If you don’t have any symptoms, then you get to proceed to your appointment.

    Now there are a couple of things that you’ll notice in our clinics that have definitely changed. First, we made the very difficult decision to not allow patients to have visitors with them, with few exceptions for those appointments and that’s again to maintain the safety of all of our patients and staff.

    Second, we’re also providing all patients and staff with masks upon arrival. And they are required to wear those masks at all times and all MSK locations.

    Third, we’ve actually increased how often we’re cleaning. So you’ll see a lot of folks that are cleaning around and the hand sanitizers are widely available at entrances as well as elevators and other frequently location, look other locations in the clinic. And then lastly, social distancing is really a top priority, which is strictly enforced.

    So, lots of different interventions that we hope will ensure that we are continuing to deliver the cancer care that our patients desperately need while keeping the safety of our patients certainly as the North Star, if you will.

    Lisa DeAngelis: Thank you. And Diane, Tobias had mentioned how the vast majority of our patients who test positive for COVID-19 are actually managed and cared for at home. And yet, we’ve all – we’ve been concerned because of their – the vulnerability of them having cancer as well as COVID-19. So we have implemented a very comprehensive system to follow them closely. Could you just comment on that for a minute?

    Diane Reidy: Absolutely. So we have developed what we’re calling the COVID cohort monitoring team that we’re very proud of. It’s made up of over 50, nurse practitioners, eight doctors and eight nurses. And so anytime that one of our patients test COVID positive through our lab, they’re automatically part of this cohort monitoring team.

    And so what that means is a nurse will call the patient explain that we’re going to be following them. And every day we send them a questionnaire for them to fill out to let them know that we care and that we want to know how they’re doing and how are their symptoms. If they don’t fill out that questionnaire then a nurse will also call them in the late afternoon and do all of those questions with them.

    If they have any symptoms that are concerning, we immediately call them. And that’s done actually through that questionnaire electronically. We have what we call a red alert or a yellow alert. So as soon as they, for example, make a question that says, my breathing is a little bit more shallow, we immediately will call them, ask how they’re doing. And then either a nurse practitioner or a medical doctor will decide next steps.

    We’re doing that for all of our patients that actually never were had to go to the emergency room or to the hospital. And we’ve had over 400 patients now that are enrolled in that program. And we’re also enrolling our patients that have been hospitalized or had been to the urgent care and other emergency room and following them to make sure that their symptoms don’t worsen.

    Many of those patients also have what we call pulse oximeter, so that we can actually follow them electronically to make sure that the measure of the oxygen in the blood is also appropriate to care for at home and if it’s not then we again will immediately call them and appropriate measures will be taken.

    So we really are trying to keep our patients safe by keeping them in the comfort of their own home but making sure that they know that we’re always connected, and that the care we’re providing is not just at Memorial but also while they’re at home.

    Lisa DeAngelis: Thank you. Now I’d like to invite Jeff Drebin, our chair of the Department of Surgery here at MSK to address the following questions. Jeff, many patients wrote in concerned about their surgeries that were postponed. Can you give us an update on what we are doing right now with surgeries?

    Jeff Drebin: So as many listeners are probably aware, a bit over a month ago, maybe six weeks ago, the state government as well as a variety of other agencies asked that all elective surgery be postponed. And we at that time, took a good hard look at what we do. We are the largest cancer surgery program in the country. And we do some elective surgery that could be safely postponed but we do some surgery which we’ve termed essential surgery that really couldn’t be postponed without potentially placing our patients at risk of increased risk of dying of their cancer.

    And so, we initially reached out to the faculty and asked each faculty member to look carefully at their decision making and discuss with their patients whether it was safe to delay surgery. We also created criteria which we have published in national journals, which essentially said that we would only do essential cancer cases things that couldn’t wait two to three months without having a significant negative impact on patient survival.

    We would also do things that were palliative for acute relief of pain and suffering. Things like spinal cord compression where people might become paralyzed if they didn’t have emergencies – have urgent surgery and would not do surgeries where there was a readily available appropriate and equivalent non surgical option.

    So if they could have radiation therapy or potentially chemotherapy, even if that was to be part of a combination treatment that might ultimately require surgery, it would take the need of surgery away for at least a few months.

    And in doing that, we were able to reduce our volume initially by about 50 percent. And ultimately at the height of the surge, we were doing about 20 percent as much surgery really only the cases that that had to be done, you know, in that week or close to there abouts. There are some kids who’ve gotten chemotherapy and when the chemotherapy stops, the kids have to have their surgery or the cancer will grow back.

    Other types of cancer where there is no chemotherapy and if surgery wasn’t done, they might have been at risk for it spreading or growing in a way that couldn’t be stopped.

    So we we’ve tried to be very rigorous, we – and we as a third control, we created a panel to review all cases and make certain and in some cases, push back to the surgeon and say, why exactly is it that you need to do this case? This doesn’t seem to us as though it’s really essential. And in some cases, the surgeon would say, you know, right, I think we probably could wait and others they would explain why it was essential, and we’d go ahead and get the surgery scheduled.

    Lisa DeAngelis: So thank you, Jeff. Do you think you could just address the fact that now as we’re seeing a slight at the beginning of a fall in the new diagnoses of COVID infection in the city, for example, how we might begin to start bringing people back to address their critical cancer issues and how we can assure that they are safe and coming to our operating rooms.

    Jeff Drebin: Sure. So Diane said, really, patient safety is our number one goal. And among the things we’re doing is for preoperative patients. All patients are being tested 24 to 48 hours prior to surgery at one of our testing facilities either here in the city or any of the regional facilities on Long Island, in Westchester or in New Jersey, so that patients who are acutely infected with coronavirus do not have surgery and we’ll postpone them for a couple weeks even if they’re asymptomatic and allow them to clear the virus before going ahead with surgery.

    This is safer for the patients because it’s been shown having a rip roaring infection that’s going on after your surgery makes it harder to both heal the virus and also heal from the surgery. It’s safer for the staff and it’s safer for other patients in the hospital. So we think that’s a winning strategy.

    We also screen our staff very carefully for symptoms. With a daily symptom checker as was mentioned earlier, everyone is wearing mask. Hand hygiene remains a key component that I particularly remind my faculty of on a regular basis. We have quarantined or, not really quarantined, but separated floors for our COVID patients, from the patients who are recovering from surgery or requiring medical treatment who are not infected. And we’re doing surveillance of all inpatients every three days to be certain that no one has been admitted who was not showing signs of infection but now has developed overt infections.

    We similarly have a dedicated operating room only for COVID patients. So if you’re in our operating room, and you’re not someone who’s had a COVID infection, you won’t be in a room that was just used by an infected patient that one room is being held aside only for COVID patients and is separate from all our other operating rooms.

    Lisa DeAngelis: Thank you. So I’d like to turn to Liz Rodriguez, who’s our director of nursing in our Ambulatory Care Services. So, Liz, many – we got many questions about diagnostic tests and whether it’s safe for someone to come in for an MRI or a CT scan or other testing. And in particular, were beginning to schedule and need to schedule a test that had been postponed. How are we protecting people when they come in for testing?

    Liz Rodriguez: Thank you for this question, Lisa. We remain very committed to providing care – the care that everyone needs. And as Diane mentioned, we’ve worked hard to put processes in place and facilities to ensure the safety of our patients while we continue to provide that high quality care.

    First, I think it’s very important for patients to work directly with their providers to determine the safest time for them to reschedule any appointments that have been postponed. And then prior to the visit, they will receive a confirmation call from their physician’s office where they will be asked about symptoms that may be related to COVID-19.

    If you report any symptoms, so symptoms will be discussed with your provider and your nurse so that they can determine if you should proceed with an upcoming appointment or go on for testing. When you arrive for your appointment at any of our sites, you’ll be greeted by a nurse who asked you about your symptoms. They’ll take your temperature and provide you with a mask.

    If you are found to have symptoms upon arrival or a fever, you may be offered swab testing, and your appointment might be rescheduled at that time.

    Lisa DeAngelis: Thank you. In addition to keeping our patients safe, we’re also working to keep our staff safe. And I’d like to invite Marcia Levine, our senior director of Perioperative Nursing, to talk a little bit about how we’re maintaining the health and safety of our staff. Marcia?

    Marcia Levine: Thanks, Lisa. I’d love to share some of that. So there are so many things we’ve done to keep our MSK staff safe and protected. Let me share just a few.

    So the first thing that’s really important and a lot of questions about this is do we have enough PPE, personal protective equipment. And we’ve been so fortunate to have all the personal protective equipment we need for our staff. We have a strong and very savvy procurement team who keeps us in the market and gets us whatever we need. We’ve also received a lot a lot of donations of personal protective equipment, which has helped us tremendously and we’re very grateful for that.

    We’ve also instructed all of our employees to self-monitor and if they’re not feeling well, we want them to stay at home. When we don’t want them to worry about sick time, or what how they’ll get paid, we’re taking care of them.

    They aren’t feeling well, we’ll ask them to complete a survey, which informs them of next steps. And then our employee health team and our COVID management team will work with them to decide if they need to have a test, or if they have something different, and we’ll keep an eye on them to make sure that they’re safe.

    The third thing we’ve done, which you’ve heard a couple of times about patients, but we’ve instituted a universal masking for both staff and patients at all of our sites. So that means that there’s somebody at the door that will hand both the patient and the staff a regular procedure mask, they’ll offer them some Purell to wash their hands on the way in and they’ll make sure that they’re wearing that at every entrance.

    And finally, which I think you heard from Dr. Drebin that we’ve been able to test some patients. So we’ve been testing many of our patients prior to their procedures and appointments to ensure that we’re aware of their status. That actually helps us protect both the patients and our staff as well.

    Lisa DeAngelis: Thank you, Marcia. Diane, I’m wondering if you could help address some of the questions that we’ve received about telemedicine and whether it might become the new normal after the COVID infection has at least diminished in the community.

    Diane Reidy: Absolutely. And, you know, unfortunately, as you know, there’s going to be a lot of changes to our new normal. I think one of the silver linings of this crisis has been this idea of a televisit, which is when, when we as healthcare providers use either a computer or a smartphone or a tablet to see and talk to our patients.

    And so this has been readily used during this difficult time. And it really allows us to care for our patients in the comfort of their own home and obviously a lot more safe so that they don’t have to travel and potentially be exposed.

    So it will reduce the burden and we absolutely believe that this is something that we want to carry through so that the quality of care doesn’t change, but that the patient experience is also something that we consider so very important in MSK.

    So, the answer is yes. We’ve also used it in the cohort monitoring team, as I discussed before, where our patients with COVID are being seen by these virtual visits, and again, can really help us see our patients. So we’re hoping and expecting that this type of care will continue.

    I think that many of us, you know, still love, the hugs many which we’re not going to be able to provide with our patients. And we’re not going to be able to see them as often as we’d like, until we feel comfortable that COVID has decreased in our community.

    So there may be sort of what we call a hybrid where you’ll have some patients that really do require the care and an in person type of visit and then we’ll have some using telemedicine and televisit. So I think this is a care delivery model at MSK that we have now embraced and we did it before but certainly now it’s much more readily available and more widely used.

    Lisa DeAngelis: Thank you. I’d like to bring in Neil Halpern, the chief of our Critical Care Medicine Service, who heads our Intensive Care Unit. Neil, we’ve heard so much talk about ventilators. Can you explain why some COVID-19 infected patients need ventilators and how they actually work?

    Neil Halpern: Sure. Thank you, Lisa. Sometimes the COVID-19 infection produces severe inflammation of the lungs. At an early stage, it may be that the patient develops some shortness of breath, difficulty breathing, coughing, and they could work their way through it. They may receive some oxygen support. Some of those patients are at home. However, some of them are in the hospital as well.

    The small percentage of those patients may develop a very severe pneumonia or severe inflammation of the lungs themselves. And even higher systems of providing oxygen may not be enough to get the oxygen into the lungs and into the body.

    On those occasions, the intensive care unit is called, and the patients are transferred to the Intensive Care Unit. At that time, we may still try and provide modalities of care methods to give oxygen that don’t require a machine. But sometimes those methods don’t work.

    At that point, under sedation, a tube or a plastic straw is inserted into the patient’s mouth through their trachea and into their lungs. That tube is attached to machine, which we call a mechanical ventilator. That is simply a machine that has many settings that allow oxygen to be transported through the tube into the patient’s lungs.

    As the oxygen gets into the lung, it’s able to, in essence, penetrate through the inflammation or swelling in the lungs and get into the patient’s bloodstream, providing the vital oxygen that is needed in order for the patient to maintain being alive.

    The patient is sedated during that time in order to maintain that comfort. The ventilator in and of itself is a supportive tool to provide time for the lungs to heal. And for certain of the medications that Tobias described earlier, to have a positive effect on the virus and the pneumonia. And hopefully the ventilator provides enough time for the lungs to heal. I think that is the big picture of how the ventilator works.

    Lisa DeAngelis: Thank you, Neil. And just to add that we have not had any difficulty with having adequate numbers of ventilators for whoever has required such support among our patients here at MSK.

    Neil Halpern: Yes, that that is correct, Lisa. We have been able to maintain a very adequate supply of the ventilators and all the supporting, tubing and other supplies that the ventilators require. And we’ve been very diligent about that.

    Lisa DeAngelis: Thank you.

    Neil Halpern: Thank you.

    Lisa DeAngelis: So we know that cancer can take more than a physical toll. It takes an emotional one as well. I want to bring in Chris Nelson, who is the chief of our Psychiatry Service. Chris, how can we help support our patients who are balancing not only the worries that come with a cancer diagnosis, but also the stress surrounding COVID-19?

    Chris Nelson: Yes, thank you. Thank you, Lisa. And you know, it is a certainly a stressful time and you know, I was talking with a patient this morning and he was discussing the stress and anxiety related to the cancer experience and then talked about how, you know, the pandemic on top of it has really, you know, increasing anxiety and stress and how kind of overwhelmed he was feeling.

    And I just want everyone to know that we are here to help and we are here to help support you through this experience. And so, we have psychologists and psychiatrists and nurse practitioners available, who can have individual appointments with you to help you talk through your concerns. If there’s medication that’s needed to help lower your anxiety or help address your depression that’s available.

    We’re doing all our visits now through telehealth as Diane was talking about. In pre-COVID, we were doing a number of visits through telehealth. To begin with, we’re doing probably over 200 visits a month. And now, all our staff and all our faculty are available via telehealth and so we can connect with you in your home to help you through this process.

    And, you know, other supports that at MSK, we have a wonderful Social Work Department here. And Social Work is running groups online and virtual groups. Those are happening daily and weekly. And so connecting with your social work staff and social work department can help.

    And also our Integrative Medicine Department, things like meditation, deep breathing, yoga, even exercise. All those classes are now online through our integrative medicine. And so if you’re interested in potentially making an appointment with one of our psychologists, one of our psychiatrists and nurse practitioner, you can just go to the website and just search Counseling Center and the information we brought up or you can call to make an appointment.

    Or if you feel more comfortable talking to your medical oncologist or your other physician here at MSK, you can talk to them, and they can make a referral. But we want you to know that, that you’re not alone. And we’re here to help and support you through this process.

    Lisa DeAngelis: Thank you so much, Chris. And thanks to all of you. Unfortunately, that’s all we have time for today. I want to thank you for joining our call and for sending in your questions. I know many of you had questions we weren’t able to get to during this session, but we will certainly look forward to organizing more sessions in the future.

    I’d also like to remind you that we have many resources available including information on our website at mskcc.org. I also want to thank all of our speakers for joining us today. So please be safe and have a wonderful day. And thank you.

    Operator: Thank you for participating in today’s conference call. You may now disconnect.