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Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

How I Cope with the Tsunami of Cancer and COVID-19 Info

Kevin Knopf, MD

Oncologists worldwide face the challenge of staying on top of the latest treatments, research findings, and other information that could help them treat their patients more effectively. Now, they must do so in the context of COVID-19. Here, our Curious Dr. George asks Kevin Knopf, MD, MPH, Division Chief of Hematology/Oncology at Highland Hospital/Alameda Health Systems in Oakland, California, how he keeps up.

Dr. Knopf can be reached at kevinbknopf@gmail.com. Or follow him on Twitter: @drkevinknopf

Curious Dr. George: Even without COVID-19, the field of clinical oncology is changing so rapidly. How do you, as a practicing oncologist, keep up with new information about cancer and COVID-19? On a day-to-day basis, do you mostly rely on the best medical journals, emails from medical associations, government agencies, press releases, actual or virtual medical meetings, hospital conferences, mainstream media, social media, or what?

Kevin Knopf, MD, MPH: There are three key journals I read regularly: two weeklies—The New England Journal of Medicine and Blood (the journal of the American Society of Hematology)—and the thrice-monthly Journal of Clinical Oncology (American Society of Clinical Oncology or ASCO). They all have excellent updated guidelines on cancer care, including during COVID-19. Medscape Hematology – Oncology is a fourth online publication that I read daily. There are several other fine journals in oncology* that I read, but their web presentations are not quite as robust. Together, these four periodicals have done an outstanding job of curating scientific and clinical information about COVID-19 and publishing it quickly online prior to print publication.

As Division Chief of Hematology/Oncology, I must also set guidelines and policy that affect our entire hospital and health care system. We were quick to adapt our chemotherapy infusion suite for COVID-19 safety based in part on shared information. Triage of outpatients has been an ongoing challenge and an iterative process. ASCO guidelines and rapid publication of information have been key in my ability to care for our patients.

I’ve also discovered another fascinating development on keeping up with cancer care during COVID-19. I registered on the Twitter-based community #MEDTWITTER in 2013 to follow what was happening in academic oncology, see new clinical developments, and learn and interact with colleagues. On Twitter, we debate the latest findings in hematology/oncology and share articles with each other. For the record, I think one of the first physicians to predict the magnitude of the COVID-19 tragedy is Christos Argyropoulos, MD, (@ChristosArgyrop), a brilliant nephrologist and researcher in New Mexico who pondered the epidemiology of COVID-19 well before the first case in the United States. My friend Dan Goldstein, MD (@drdgoldstein), retweeted a video featuring Italian pulmonologist’s experience treating COVID-19 in Italy on March 10—the day things really sank in for me. A video on Twitter can be worth more than 1,000 words. Now, I follow the Twitter accounts of several epidemiologists and molecular biologists engaged in COVID-19 research.

While rapid information has been brought to bear on COVID-19 during this time of crisis, many shoddy and methodologically flawed scientific “studies” have been rushed to publication. For instance, recent discussion has focused on the retraction of some highly flawed publications on hydroxychloroquine. Journalists Jeanne Lenzer and Shannon Brownlee have written eloquently about these problems.

An illustrative and highly pertinent ongoing issue is whether we should change our clinical approach to treating COVID-19 patients who have acute blood clotting disorders—strokes, pulmonary embolism, and the like—who often die, even of disseminated intravascular coagulation. This question touches on not just the biology but the nature of clinical research; it is now known that patients in the intensive care unit with COVID-19 have a high incidence of thrombotic (clotting) complications, but whether and how to intervene is being debated.

In clinical medicine, when possible, we conduct prospective randomized controlled trials to minimize confounding and bias in order to get closer to the truth of whether an intervention helps or harms a patient. The principle is that while retrospective trials are hypothesis generating, prospective trials help to prove or disprove a hypothesis. In this context, several institutions have been interpreting the retrospective data to recommend more aggressive anticoagulation for patients with COVID-19. I’ve had to sit tight and believe what I believed before—that this doesn’t make sense. On Twitter this has been debated extensively, even with a picture of a patient who died from a bleed into the brain caused by excessive anticoagulation (arguing against this practice). For my institution, I have not recommended changing our approach of not anticoagulating COVID-19 patients, but I am monitoring the evidence daily.

So much is changing in our communication about cancer care as a result of COVID-19. I gave my first online lecture to an international conference on March 9. And, our usual ASCO meeting of 60,000 people in Chicago was instead held completely online while (coincidentally) peaceful protests and violence in the streets erupted over George Floyd’s death. The convention center for this meeting had been converted into a COVID-19 hospital in anticipation of a tsunami of cases in Chicago. Interestingly, the academic oncologists on Twitter are mostly commenting about how nice it is to not have to travel for a meeting; the only part we seem to miss are the social interactions with each other.

The internet has dramatically improved how we practice medicine and share knowledge in cancer care. Now, COVID-19 is another jolt to the system that will change how medical information is generated and disseminated. As a physician practicing at a county “safety net” hospital, I predict dramatic changes in cancer care as more than 27 million Americans have already lost their health insurance due to the pandemic. This erosion of coverage may herald a sea change towards more value-based cancer care as the finances of cancer care in 2020 and beyond are challenged.

*Additional important journals for hematologists/oncologists include The BMJ, The Lancet, The Lancet Oncology, JAMA Oncology, The Oncologist, Clinical Advances in Hematology & Oncology.

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Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

How the Coronavirus Pandemic Impacts Cancer Care: Our Survey Results

Lola Rahib, PhD

The ongoing COVID-19 pandemic presents unprecedented challenges to cancer patients. Many have experienced changes to their care, and some face increased risk of infection or worse prognosis if they are infected. In partnership with the company xCures, Cancer Commons is studying how COVID-19 impacts cancer patients.

Here, our Curious Dr. George asks Cancer Commons Director of Scientific and Clinical Affairs Lola Rahib, PhD, about our findings so far. Dr. Rahib can be reached at lola.rahib@cancercommons.org.

Curious Dr. GeorgeCancer is listed as one of the preexisting conditions that may result in increased susceptibility to the harm caused by COVID-19. In addition, the mass shutdown of many of society’s activities intended to mitigate the pandemic has major impacts on functions of medical care.

Cancer Commons has launched an FAQ page to inform cancer patients of these many interactions. In addition, you have performed a survey of cancer patients to identify their experiences during this pandemic. What are some of your main findings?

Lola Rahib, PhD: Our goal was to understand the impact of COVID-19 on cancer patients through a questionnaire completed by them or their caregiver. A total of 112 patients or caregivers completed the questionnaire from March 24 to April 15. Ninety of those who completed the survey had previously registered for Cancer Commons’ services and received the survey by email. The remaining 22 patients completed the survey through social media platforms.

Of the 112 patients and caregivers who completed the survey, 78 (70%) reported that they or the patient they care for was currently receiving cancer treatment. Canceled or postponed appointments due to COVID-19 were reported by 32 (29%) participants. Thirteen (12%) reported treatment delay because of COVID-19.

Six patients (5%) were newly diagnosed and had to make a treatment decision about a new cancer diagnosis during the COVID-19 pandemic. Twenty-one (19%) patients had to make a decision about a treatment change.

Eighty-three reported on whether COVID-19 affected any treatment decisions they had to make. Of these 83, 24 (29%) reported that COVID-19 affected their treatment decision, and 23 gave an explanation. The most common explanations of how COVID-19 affected treatment decisions were “changes to travel for treatment/change in place of treatment,” “changes in travel/living situations/other personal changes,” “changes to surveillance,” “changes, delays, or not receiving treatment to decrease risk of COVID-19 infection,” “continued on treatment that is not working,” and “did not continue to pursue a clinical trial.”

Symptoms of COVID-19 (coughing, fever, shortness of breath) were reported by 16 (14%) patients and caregivers. Six (5%) patients had COVID-19 testing, with one patient still awaiting results, and all of the other five tested negative. Increased anxiety about cancer treatment due to COVID-19 was reported by 72 (64%) participants.

Most of those who completed the survey were the patients themselves (72%), 13% were caregivers, and 15% did not report whether they were a patient or caregiver or played another role. Fourteen percent of the patients were 49 years old or younger (7% younger than 40), 48% were between the ages of 50 and 69, 13% were 70 to 79, 3% were 80 or older, and for 22% of the patients, their age was unknown. Most patients were female (66, or 59%), 30 (27%) were male, and for 14%, the sex was unknown. Thirteen types of cancers were reported, the most common cancer types being breast, lung, and colorectal cancer. Most of the participants were from the U.S. (70%) with 12 countries represented including Italy (7%), Canada (4%), Australia (3%), and the U.K. (3%).

To conclude, changes to appointments, treatment delays, and the impact of COVID-19 on treatment decisions were reported by patients and caregivers. The majority of patients (64%) reported increased anxiety about their cancer treatment during the COVID-19 pandemic.

Cancer Commons remains dedicated to helping patients and caregivers navigate their cancer journey and ensure they are able to access the best possible care. Get help now.

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Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

How to Beat COVID-19 with Real-Time, Real-World Data

As the COVID-19 pandemic continues, researchers around the world are working quickly to develop strategies to treat and prevent this disease. In partnership with the company xCures, Cancer Commons is studying how COVID-19 impacts cancer patients. Meanwhile, xCures has launched larger initiative, BEAT19, to gather information from everyone and anyone who wishes to participate—whether they’ve had cancer, COVID-19, or neither.

Here, our Curious Dr. George asks xCures’ Vice President of Clinical Development Mark Shapiro, PhD, about BEAT19. Shapiro is Principal Investigator of the BEAT19 registry (Behavior, Environment and Treatments for COVID19) and can be reached at mshapiro@xcures.com.

Q: In 2000, we said that “the internet changes everything,” and it did. In 2020, we can say that “COVID-19 changes everything,” and it will. The good news is that the internet allows a whole new approach to studying the coronavirus that causes COVID-19 using clinical trials to produce real world evidence (RWE). How might RWE be applied now to study COVID-19, using innovative methods?

Mark Shapiro, PhD: I certainly agree that everything has changed. This pandemic has moved much faster than biomedical science is generally designed to move. It is also a stark reminder of the connectedness of people, not just online but in real life. There is an information vacuum, and if we as scientists don’t fill it with accurate information, it will get filled with half-truths and speculation. The internet spreads information quickly, but it doesn’t discriminate.

I’ve been amazed by the efforts to publish so many small studies about COVID-19 in days or weeks, but they often raise as many questions as they answer. Having communicated frequently with friends in Italy, Singapore, and Hong Kong since January, I had the feeling that it would be increasingly difficult to run traditional clinical trials if a great many of the people experiencing this illness would be in isolation at home.

So, a small group at xCures worked tirelessly to launch an electronic registry, BEAT19, for daily symptom tracking with the ability to go back to later link up to medical records. We had some sense of the symptoms and have deployed patient-reported outcomes in our other work. Of course, there isn’t a validated SARS-CoV-2 symptom questionnaire, so we tried to adapt various questions that could characterize the natural time course of symptoms. The goal was to generate data that would help collective understanding the disease in an empirical way.

With BEAT19, we are trying to observe the symptom trajectory of COVID-19 and measure endpoints, such as seeking testing or hospitalization. The natural experiment investigates how the trajectory or endpoints differ between similar patients on different anti-hypertensives. I’m sure you saw yesterday’s report in the New England Journal of Medicine; the hypothesis around angiotensin signaling has been around for weeks. Similar questions have been posed about classes of diuretics and more generally about corticosteroids. While a vaccine is urgent, in the short term, answering these questions about how medical management could reduce the risk or severity of infection can have a major impact.

For a few weeks, we have also been aware of people taking hydroxychloroquine or lopinavir/ritonavir, so any evidence people on those medications have different risk or disease severity than similar people is valuable, for example in forming a strategy to protect front-line healthcare workers.

We are committed to running BEAT19 as a public service and have already received offers of collaboration from dozens of people in industry, academia, and government. A number of them have suggested important hypotheses to test, so we’re organizing working groups to formulate and design the analyses.

Thank you for your question, George. Please let your readers know that they can learn more or sign up at BEAT19.org.