Information Session: Creating a Safe Space for Your Cancer Surgery

Corporate Speakers

• Jeffrey Drebin; Memorial Sloan Kettering Cancer Center; Chair of the Department of Surgery
• Tobias Hohl; Memorial Sloan Kettering Cancer Center; Chief of the Infectious Diseases Service.
• Marcia Levine; Memorial Sloan Kettering Cancer Center; Senior Director of Perioperative Services from the Department of Nursing
• Gregory Fischer; Memorial Sloan Kettering Cancer Center; Chair of the Department of Anesthesiology and Critical Care Medicine

Jeffrey Drebin: I want to begin by welcoming everyone to this Information Session on Creating a Safe Space for Your Cancer Surgery.  I'm Jeff Drebin, Chair of the Department of Surgery here at Memorial Sloan Kettering.  I'm also a surgeon who specializes in pancreas cancer.

I want to thank those of you who've joined our call today.  I want you to know that Memorial Sloan Kettering is working hard to keep you and your loved ones safe when you come for an appointment or treatment at any of our locations.

Today we're going to discuss timing of cancer surgery and safeguards we have in place to protect you when you come for your surgery or the appointments leading up to and after your surgery.  We understand that you may be feeling particularly vulnerable during this time.  Many of you have had your surgeries or appointments postponed.

We have a panel of experts who will be participating in this call, including Marcia Levine, Senior Director of Perioperative Services from the Department of Nursing; Greg Fischer, Chair of the Department of Anesthesiology and Critical Care Medicine; and Tobias Hohl, Chief of the Infectious Diseases Service.  With this group, we'll discuss many of the common concerns people wrote to share with us.  And we will try to get to as many of the questions that you send in as possible during our time together. 

I want to remind you that your MSK doctors and care teams are ready and willing to talk to you directly about your concerns.  I encourage you to reach out to them to discuss the next steps in your care, and to ask them any questions that we are unable to answer here today.

Questions and Answers 

Jeffrey Drebin: I'm going to start with questions that really came into to the Department of Surgery, and this is a question that has -- it's a trick question.  It said, when will Memorial Sloan Kettering resume surgery?  And the reason it's a trick question is we never stopped doing surgery.

It's important to recognize that the edict to stop elective surgery made specific recommendations with regards to continuing to do essential surgery.  And about 80 percent of what we do at Memorial Sloan Kettering Cancer Center actually fulfills the criteria of the State of New York and the American College of Surgeons as level 3A, the highest level of essential surgery.

So we did have to decrease our volume significantly because in ramping up for the COVID surge, we converted a fair number of our sixth-floor operating rooms to intensive care units.  And we're only able to continue doing cancer surgery on the second floor.  However, almost three weeks ago now, we were able to convert the operating rooms back, extensively cleaned the entire OR suite, and all of our operating rooms are back up and running.

There was a follow-up question which was about, will elective surgeries resume?  The resumption of elective surgeries in the State of New York is really the governor's decision.  It's a state edict.  And so we are complying with that edict.  We have postponed some surgeries, which are not elective, but could be safely postponed for up to several months.  But we're now contacting some patients and saying it was safe to wait a few months but probably not safe to wait many months.  And it's very clear from studies both in the United States and in the United Kingdom, that delaying some cancer operations more than a few months can increase the risk of people dying of their cancer.  So although waiting has been okay for a few months, waiting is not necessarily a good thing to do for six months.  And for many patients the time is now.

I'm going to switch over now to our panel with some of the questions that may be useful for them.  I wanted to start with Tobias Hohl, our Chief of Infectious Diseases, and ask Tobias to give us just a little bit of his view on the New York Metropolitan environment and testing.  What is the current status in terms of prevalence?  Where do you see this going?  Is it going to stop or slow down for the summer and maybe get worse again later in the year?

Tobias Hohl: Jeff, thank you for inviting me onto this call.  And I want to state the obvious that New York City and the Tri-State area has been hit hard by COVID-19.  And we've been the global epicenter for this pandemic now, starting in late March and early April.  So we know that in New York City, about 200,000 individuals have contracted COVID-19. 

The vast majority, the vast overwhelming majority of these individuals, including patients with cancer have recovered from COVID-19.  Memorial Sloan Kettering, like all of hospitals in this region, has become very skilled at treating patients with COVID-19.  So we have gained expertise in how to treat COVID-19.  In case you need to be admitted with COVID-19 at our center, we specifically have gained expertise in how to treat patients with cancer who contract this disease.

I think a very important point that Dr. Drebin mentioned was how important it is, though, to go ahead with necessary cancer treatments, including surgeries.  For the vast majority of cancer patients, cancer is a greater threat to a patient's life than COVID-19.  And we have a very strong team of infectious disease experts that can back up your MSK cancer surgeon in case that eventuality should occur.

The good news is that New York City and the Tri-State area are now really on the downslope of the surge that we experienced in March and April.  And that's really a credit to individuals like you who've taken the social distancing, the physical separation, the handwashing, and all of these other important measures to mitigate the spread of COVID-19.

It's really -- I'm not able to say at this time, whether we'll see another surge later in the year.  That really depends on continued decisions, you know, at the state and at the federal level.  And really what's key to limiting the outbreak now is the ability to test large numbers of individuals and to identify cases very rapidly, and then to trace contacts and isolate individuals so that they can't be any further disease spread.

So we're going to learn over the summer and in the early fall as to how effective these statewide and national measures have been.  But I'm quite confident that in the Tri-State area, there's been enormous progress made.  And we're really seeing far, far fewer cases now than we were seeing a month ago.

Jeffrey Drebin:  Thank you, Tobias.  A follow-up question is pre-procedural testing.  And for some of our listeners, maybe it would help to clarify, we hear about virus testing and we hear about antibody testing.  How do these differ?  And how is MSK using testing to improve the safety of our patients and staff?

Tobias Hohl: We have both of these types of tests available at MSK.  The viral testing is the test that we use in order to find out if someone's acute illness is actually due to COVID-19.  And many of you may have seen Governor Cuomo get this test at his news briefing yesterday.  So that's a test in which a swab is placed inside a patient's nose.  And then the swab is evaluated for the presence of small pieces of the virus's genome.  And that's how we detect COVID-19 in someone who is acutely ill.  This is a type of testing that we do before a patient undergoes a surgery. 

The contrast to that is the antibody test.  The antibody test tests for a sign of a prior infection.  So we mount antibody responses after COVID and after other infections approximately one to two to three weeks after the infection has started.  And so, what the antibody tests help us with is to understand what proportion of our patients have been exposed to COVID in the past.

So in terms of moving ahead with a cancer surgery, it's really if we test an individual, it will be with the nucleic acid test to test directly for the virus.  And that's the type of testing that's occurring now in the pre-surgical workup in that space.

Jeffrey Drebin: So, yes, I think it's important to emphasize all patients arriving at Memorial are being tested for the virus, whether they come for surgery or for other procedures or come through our urgent care center as we work to be the safest possible environment for our patients and staff.  The staff are also being tested on a regular basis.

There's a one short follow up question, Tobias.  Somebody asks, can they get the antibody test before surgery when they get the virus test?

Tobias Hohl: Really, the recommended test is the virus test.  Because we want to know if someone is in the pre-symptomatic period of an infection.  What I mean by that is that some individuals have a positive virus test before they develop COVID-19 symptoms.  The typical period of time there is approximately two days.

And so the scenario that we're trying to avoid is that someone feels well before their surgery doesn't know that they have COVID goes on and has a major cancer surgery, and the day after their surgery, they become sick with COVID-19.  That's the scenario we want to avoid.  And the test that allows us to mitigate that risk is the virus test.  The antibody test does not play a role in order to figure this important question out.

Jeffrey Drebin: Thank you, Tobias.  I'm going to shift gears to a different line of questioning and this one goes to our operating room, head nurse and director of perioperative services, Marcia Levine.

Marcia, the question we heard most from the callers prior to today was about our visitor policy.  And I wonder if you can talk to us about that policy and how we're helping people connect with their loved ones at Memorial Sloan Kettering during a period when visitors are extremely limited, and that's actually via a state policy as well as our own policy.

Marcia?

Marcia Levine: Hi, sorry, I was on mute.  I apologize.  The policy is one that we're obligated as you suggested under the governor's mandate.  However, we put a bunch of things in place to help all of you.

Our surgical patients all receive a phone call the day before confirming the time of their arrival and at that time have the opportunity to ask any questions they may have of the caller.  On arrival, you'll be greeted by our concierge who will ask you for contact information of the person you'd like us to keep in touch with throughout your surgery time.

We also have a program where we have nurse liaisons.  These are RNs who make rounds in the operating rooms on every patient every hour and who will be in touch with your contact person if you agree that, that's okay.  And at the end of your surgery, you can expect that the surgeon will call your family member or the point person for you so they understand what's going on and that everything is okay.

The other thing we've done is if you're going home the same day of your surgery, your nurse will make a call to the person who's picking you up; review all of your discharge instructions.  So there's a second person that's heard them besides you after anesthesia, and then they'll take you home.  But if you're staying overnight, the nurse on the unit will be able to assist you to contact your family during your stay either by regular telephone or by a video call with tablets at the bedside.

Jeffrey Drebin: Thank you, Marcia.  I'm going to switch to Greg Fischer, our Chair of the Department of Anesthesiology and Critical Care Medicine, to talk about how we're protecting our patients in the operating room specifically during intubation.

Greg, one writer wanted to know, do the anesthesiologists that intubate COVID-19 patients also work in the operating rooms?

Gregory Fischer: Thank you so much, Jeff.  And thank you for including me on this panel.  It's a wonderful opportunity to give the listeners input into what goes on from an anesthesia perspective.

So the Anesthesia Department, nothing is more important than the safety of our patients.  It's sort of the core of our specialty is we're looking out for safety and how can we guide you through the whole perioperative experience.  And it's really a partnership by the anesthesiologists being safe and patients being safe.  And you heard what we do with our patients with having them tested within 48 hours before the procedures.  We do similar things with our anesthesiologists and with our nurse anesthetists.  They're also screened once a week.  Right now, going forth, for having the virus or not, and we only allow staff members back who screened negative. 

And we also use maximum safety protective equipment, PPE, that I'm sure many of you have heard a lot about.  And we have enough PPE right now at Memorial Sloan Kettering to fulfill our mission.  So your anesthesiologists will have face masks on, they will have gowns on, and they'll also have face masks on that sort of look like welder's helmets, all in an effort to sort of keep the droplets spread at a minimum.

Now the one specific question was geared about what happens during intubation.  Intubation is a process where the anesthesiologist puts a breathing tube into the patient's airway once the patient is off to sleep to make sure that the patient has plenty of oxygen during the surgical procedure.  You won't have any recollection of us putting this tube in.  But putting the tube in does cause aerosolization.  And this is where we would be at most danger of spreading the virus.

So what is done there is, like I just said, we go with maximum PPE protection.  The anesthesiologists are screened once weekly, and the patients are screened 48 hours before the surgical procedure.  That allows us to keep the risk at an absolute minimum.

Now to the last question that you asked to anesthesiologists that intubate COVID-19 patients also work in the operating room.  They do not on the same shift.  So we have a special intubating team that goes around the hospital, meaning outside of the operating rooms, and they work week on, week off.  And when they're out there, that's all they do is they intubate patients throughout the hospital.  They do not work in the operating rooms.

Jeffrey Drebin:  Thank you, Greg.  That's very helpful.

Marcia, you know, the safety is clearly number one for everyone.  Can you talk about what other precautions we're taking for our patients?

Marcia Levine: Sure.  Thanks Jeff.  So it's a great question.  And we put many safety protocols in place for both our patients and our staff.  The first thing I'd like to share is that none of our COVID-positive patients are on the same units as our non-COVID patients.  So if you had a surgery and you're an inpatient, you would be on a COVID-free unit.  Unless you were COVID positive and then you would be on a COVID-positive unit.

So we've implemented a universal masking plan as well.  All employees working at MSK in the clinical sites, in the lab facilities must wear a mask at all times in all public spaces, taking care of the patients, including hallways and elevators.  In the patient-facing arena, they would wear a face shield as well when taking care of you.

When you arrive at our hospital, you'll be offered one if you're not already wearing one because the patients must wear a mask as well.  We've also been very fortunate, as Dr. Fischer said, to have all of the PPE, personal protective equipment, required for our team.

As you heard from Dr. Hohl, we’re also performing COVID-19 testing on surgery patients within 48 hours of your procedures so we can ensure whether or not you have COVID-19.  If your test is positive, we'll weigh the risks and make a decision with you.  Your surgery must be performed right away because it's critical or if it can wait a few weeks until your test is negative.

The other thing we have and Dr. Fischer mentioned this, we have a dedicated operating room for patients who have COVID-19.  And we provide the highest level of personal protective equipment to the staff caring for them.  You would not have surgery as a non-COVID patient in an operating room that COVID patient had surgery on.

Jeffrey Drebin:  Thank you, Marcia.  That's very helpful.

Greg, sort of a related question about ventilators in the hospital.  You know, we're a big hospital but we also have a lot operating rooms.  Do we have enough ventilators?  Do we have enough PPE?  And do patients in the operating room use ventilators that have been used by COVID patients?

Gregory Fischer: Yes.  So we initially had, just like every other hospital back in March, issues with acquiring PPE.  But for the last few weeks, our PPE stocks are full.  We have plentiful.  Our staff as well as our patients receive anything that they need, whether those are N95 masks.  Everything is there which needs to be done so that we can fulfill CDC criteria.

As far as the ventilators are concerned, we as an institution, we're very blessed.  I know many of you have heard horror stories from some of the other larger hospitals around the New York area or in Italy or in China, where they were running out of ventilators.  That was never the case at MSK, we always had more than enough ventilators. 

And we were actually lucky enough that we were prepared to take a surge of critical care patients that was occurring in early April into our operating rooms.  And like Dr. Drebin mentioned before, we did turn our operating rooms into ICU available locations, but we were lucky enough that we never had to pull the trigger there.  So the operating room never saw COVID-positive patients.  They were cleaned about three, four weeks ago and it put back into service for what they were actually intended to do. 

So those ventilators who have never seen COVID-positive patients.  Now what we have put onto all of our ventilators are extra filter so they have their own little HEPA filters.  So even if a patient with COVID would be on those ventilators, the virus would not be able to reach the inside of the ventilator.

There's only one room right now at Memorial Sloan Kettering that we have designated a COVID room.  And that ventilator, of course, has been used to treat COVID-positive patients.  But that ventilator stays in the that room and is cleaned appropriately after each use.

So any patient who has not tested COVID positive and comes to Memorial, they can rest assure that they will have a clean ventilator that is being maintained in accordance to the company's mandates and has never been used on a COVID patient before.

Jeffrey Drebin: Thank you, Greg.  On the subject of testing, another question had to do with the staff.  And, Marcia, I'm wondering if you can go through how are we monitoring and testing our own staff as well as patients who are in the hospital for a prolonged period of time?

Marica Levine:  Sure.  Thanks, Jeff.  So let me talk quickly about the patients.  Our patients in MSK, no matter what site they're at, if they are an admitted patient, they can surveillance test, which means the swab test that Dr. Hohl mentioned earlier, every 72 hours to make sure that nobody turns from negative to positive.  And then we also have the ability to test people that are positive that are on our positive units to see if they've turned negative.  And several of them have which is great news for us.

As far as our staff, we're doing a bunch of stuff that I think is exciting.  So we have a few protocols in place to monitor the health of our team.  Each day before our employees come to work, they fill out an electronic tool about how they're feeling which includes all of the COVID-19 screening questions that you may have seen that the CDC put out.

Once completed and submitted, and based on the answers they gave, they're directed to either report to work and they get an e-mail that says just such that that they can show to their manager or to stay at home.  If they're directed to stay at home, they'll complete a second survey, which sets them up for COVID-19 testing, so we can be sure that their symptoms are not of COVID-19 and that they may have allergies or they may have other medical issues that do not, you know, make them well for work.

The other thing I think Dr. Fischer mentioned earlier is that we're performing weekly COVID-19 surveillance testing of all of our staff that are patient-facing.  That's where we started, and we're expanding that out to other staff if they're not patient-facing.

Jeffrey Drebin: Thank you, Marcia.  Tobias, I'm going to come back to another infectious diseases question.  This is a question from a patient.  Will I need to self-quarantine when I'm discharged after my surgery?  What's the best advice for people to follow once they leave the hospital?

Tobias Hohl: That's a great question.  And the good news is that you will not need to self-quarantine when you are discharged from the hospital.  If you are going home after your surgery, you should be free to live in the same home with the same people that you lived in or quarantined with prior to the surgery.

Now, after your surgery, you will probably get a lot of inquiries from friends and more distant relatives about how the surgery went.  They should not be visiting you.  They should -- you should be telling them about your surgery over Zoom or over Skype or by electronic means.  So if you aren't already quarantining with your immediate family now, I think it would be best to go back to that quarantine status until it is lifted more widely in whatever region that you live in.

Once you leave the hospital, you'll obviously need follow-up care.  And one of the big changes we've seen at Memorial Sloan Kettering is that we've converted a lot of our visits into video telemedicine visits.  So for some of you, it may be appropriate to have follow up care via video hookup.  And that's -- and we think that's an important safety consideration for our patients so that you're not exposed to the dangers of transportation and the trip -- and you're safe the trip to MSK.

Now some of you may need to come back to MSK to visit your surgeon or your care team or to discuss next steps in your cancer care.  And you'll notice that MSK -- you may see cleaning crews around MSK.  So we're trying to keep our facilities as clean as possible.  There is enhanced cleaning protocols in place.

The waiting rooms look different because the seating arrangements are now set up so that you can socially distance while waiting for your appointment.  And you will see staff wearing personal protective equipment and you'll be offered personal protective equipment yourself so that there's going to be the physical barriers in place when you interact with your care team to mitigate any possibility of viral spread.

Jeffrey Drebin: Thank you, Tobias.  So sort of follow-on question, you know, there were some reports particularly early in the pandemic out of China that patients who got cancer treatment, whether it was medical oncology treatment or with chemotherapy or surgery who also had COVID had a very, very bad course with very high morbidity and mortality.  Can you talk a little bit about the risk for cancer patients in the era when COVID-19 is not going away?

Tobias Hohl: Yes, I'm happy to do that.  I think -- we have actually studied this question in some detail.  And one of our findings is that cancer patients who need major surgery and have had major surgery within 30 days of a COVID diagnosis do not seem to feel worse than cancer patients who have not had a major surgery.  So we're not seeing a detrimental impact of major surgery on COVID outcomes.  And the way we define major surgery is any procedure that requires general anesthesia. 

So from that, we've learned that we need to continue to treat the cancer because cancer, in almost all cases, is a more life-threatening event than COVID-19.  And we don't see in our data, an impact of having undergone cancer surgery and then subsequently acquiring COVID-19.

So the data from China were quite premature in the sense that very small numbers of cancer patients were studied.  And one important distinction in these early studies has been is that the distinction between COVID mortality and cancer mortality was not really clearly delineated.  And I can't stress enough how important it is for patients to get the best possible therapies for their cancer, whether that's surgery, whether it's radiation, whether it's chemotherapy.  And we have a very strong team here of infectious disease experts that should you contract COVID will be able to work with your oncologists, your surgeons, and your radiation oncologist to get the best possible outcomes for you.

Jeffrey Drebin: Thank you, Tobias.  And just to sort of flip the results around but with the same conclusion, when we've looked at surgical complications in patients who have COVID, they don't appear to be any different than surgical complications in patients who do not have COVID.

So, again, excellent surgery, excellent care by our infectious diseases teams can both optimize outcomes for cancer.  And if COVID does interfere with the situation, I think we're in a good position to manage it.

As Tobias said, for many of our patients, if one looks hard at the COVID data for patients who are older, for patients with morbidities, medical problems.  There might be a 10 percent or even 15 percent chance of dying if they get a COVID infection.

For most of our cancer patients, flip that around and tell them they have a 90 percent, 85 percent, 90 percent chance of being cured, they would take that in a heartbeat.  So it's important to recognize the risk of dying of cancer is something that all cancer patients face and the risk of dying of COVID.  I'm pleased to say something most COVID patients don't face now with our testing, with the other steps we're doing, very few patients are likely to increase their risk for COVID if they decide to proceed with their cancer care.  And of course, if they don't, there is substantial evidence that their cancer may go from curable to incurable.

I did get a question specifically about that and about cancer surgery.  And the question is, what determines if a cancer patient is a good candidate for surgery?

So as was mentioned earlier, if someone is in the throes of a COVID-19 infection which generally lasts a week or two, we will often postpone the surgery to let them clear the virus, particularly if they're highly symptomatic.  It's both kind and it exposes other patients and staff to less risk.  If patients have a really emergent need for surgery, we do their surgery in our COVID operating rooms and have isolation procedures so that they are never in contact with non-COVID patients.

For all cancer surgery, independent of the COVID environment, the real question is what's the potential benefit and what's the risk?  Is there a chance to cure the patient or prolong their survival or substantially palliate pain or other symptoms?  Those are the potential benefits of surgery.

And then as we weigh the risks, the risks are, of course the risks of the surgery itself, and of the complications of surgery that happened with any big operations, you know, strokes, heart attacks, infections.  Most of those risks are quite low.  And as both Dr. Hohl and I mentioned, it appears that the risks of COVID do not really add to the underlying risks of cancer care.

So the real balance is, is the patient able to have surgery from their overall medical condition?  And with Dr. Fischer's outstanding anesthesia group, we can operate on patients who do have some medical problems and bring them through well.  And then is there a chance to cure or palliate them in a way that they'll benefit from?  And is that a better potential outcome than the risk of complications from the surgery.

So that's a decision really to discuss with your surgeon and with your medical oncologist or family doctor who's talking about referring you to a surgeon.  But I hope our patients will recognize that Memorial has long tradition as both the first cancer hospital in the nation, the largest cancer surgery program in the country, and one that has outcomes that really are at the very forefront in terms of bringing people through operations and achieving long-term cures.  And so we'll do our best to offer that to all our patients and in the COVID era to minimize their risks and manage problems that may be related to COVID.

Tobias, I'm going to push back to you with one more question, which is, were there any general tips for strengthening people's immune systems, either before or after surgery?

Tobias Hohl:  I think that many of the things that we were doing in the past, you know, helped patients prepare for surgery.  And that's really not different in the COVID era.  So eating well, sleeping well, getting regular exercise are all things that can help in the -- you know, prepare a patient for surgery.  And sometimes this is more challenging now in the COVID era with restrictions on going outside.  And so we recognize that.  It's really important to physically distance yourself and maintain the quarantine and the social distancing patterns that we've had in the Tri-State area now for some time.

The other important things are frequent hand washing.  If you go outside to exercise, you know, and to take a walk to prepare yourself for your surgery, please wash your hands when you leave your house.  And please wash your hands when you come back home.

Similarly, regular hand washing is just really, really important and probably the single biggest active intervention besides social distancing in terms of mitigating the risk of acquiring COVID.

Jeffrey Drebin: Thank you, Tobias.  To finish up, there were a number of people who wrote questioning how we made decisions to postpone surgery back when we were only able to do about 20 percent of our normal volume.  And as we are ramping back up, is there a backlog or will there be a backlog as we're able to do more surgeries?

So I wanted to spend just a moment describing the process we underwent at the time that we really were facing the need to limit how much surgery we could do in a particular time because most of our operating rooms, as Dr. Fischer had mentioned, had been converted to potential ICU space.

And during that time, a multi-disciplinary committee, including nursing, surgery, neurosurgery, and anesthesia and critical care, medicine reviewed all of our cases twice daily.  And all surgeons in the department were asked to think very carefully about whether patients could have their surgery postponed without negatively impacting their survival, whether there were alternative treatments that might give equivalent results such as chemotherapy or radiation.

And so the first step was really a conversation between the surgeon and their patients.  And then, if the surgeon felt that the surgery did need to proceed at that time, it was reviewed by this multi departmental committee to be sure that we agreed with that decision.  Occasionally, we would push back to the surgeon for more information or to be clear on why the surgery needed to be done at that time.  And then we were able to get everyone scheduled who really needed to be done. 

So I think we were accurate and at the same time fair and took the best care we could for patients.  But it's important to recognize that in some cases in postponing surgery, we did not impact on patients' potential cancer outcome.  But that's not a postponement that will be able to go forever.

And so, surgeons are contacting patients, and patients are contacting surgeons, asking if now is the time.  And I think the answer, again, needs to be an individual decision made by patients in consultation with their surgeons.  I think our -- what we're doing at Memorial has made our environment very safe.  And in fact, I think you're safer within our four walls than you are in the grocery store or out in the park because of the level of testing we're doing.

And in those conversations with your oncologists, whether surgical oncologist or medical oncologist, the key question is, does my cancer need this care?  And if so, you know, when can we get it scheduled?  If it can be postponed or you want to postpone it longer, what are the risks of doing that?  And to again, weigh the risks and benefits of surgery and knowing that this environment is not going to go back to the way it was.  But I think at this point we have done what is a good job of making things safe and enable us to continue to deliver the most effective cancer care.

So I'm going to stop here and wrap up.  I want to thank everyone who submitted questions and to all of you who took the time to join this call.  We hope you found it informative and helpful.  And I also want to thank our speakers who provided so much useful information.

We do plan to host more calls like this in the future, and we look forward to speaking with you again.  A replay of this call will be available soon on our website.  And if you want to listen, you can visit the website for the update to this and other calls at mskcc.org.

I also want to encourage you again to be in touch with your MSK doctors and care teams.  We're dedicated to moving your care forward because you shouldn't put cancer care on hold.  Please do be safe.  Take care of yourselves and your loved ones, and remember to wash your hands.

Thank you to everyone.  Good afternoon.

Operator:  This concludes today's call.  Thank you for joining this information session for patients and caregivers.  Have a great day.