Alicia Morgans: Hi, this is Alicia Morgans, Associate Professor and GU medical oncologist at Northwestern University. I am so, so appreciative to have here with me today, Dr. Phil Koo, who is the Division Chief of Diagnostic Imaging at Banner MD Anderson in Phoenix, Arizona and who is also just a good friend and someone who leads a lot of people and thinks a lot about how to care for his division and his patients in the setting of COVID-19. Thank you so much for being here with us today, Dr. Koo.

Phillip Koo: Oh, it's my pleasure to be here. Obviously it's a very important topic and a very timely topic that we're facing across the country and across the globe.

Alicia Morgans: I agree and I appreciate your time. So as we're thinking about this, as you're thinking about this, what have you noticed in your day-to-day clinical practice and what changes have you made to really keep your patients and your clinicians safe as you're thinking about both imaging, but also as a nuclear medicine physician, nuclear medicine treatments, and imaging?

Phillip Koo: So, it's a challenging question and I think there's no real single answer to this that you could apply across the world. Each community has its own sets of challenges that they're going to have to deal with. And also the timing of this is very different. So clearly you look at cities such as New York in the U.S., which is much more advanced, Italy, Spain, South Korea, and China. And then you have some cities that have a little bit of a luxury to plan for more serious downstream effects of COVID-19 so it gives us a little bit more time to plan ahead. For Phoenix, one of the unique challenges that we face is the fact that we have cancer patients but we also have a slightly older population who we know that COVID-19 affects the older populations worse than it does the younger and the healthy populations.

So for that, it's really about how we define which patients you can safely defer care and which patients you can't. And I think sometimes the answer to that question is very black or white. So when it comes to screening mammograms, screening CT colonography or whatnot, we feel pretty comfortable that we could delay that exam either four or eight weeks and hopefully, the situation will be better and the patients can come in and get those tests.

For certain patients who are undergoing therapy. clearly that is probably not a patient population where you can safely delay visits and then you have patients who are being followed up not on current therapy that maybe you might be able to safely extend that visit another four or eight weeks. Regardless of the situation, I think it's so important to bring up the idea again about multidisciplinary care. So we know that multidisciplinary care can provide better care in normal times. In times such as this, I actually think it's even more important because the discussions that you'll have with the medical oncology team, urologic oncologists and the radiologists and pathologists can help the whole team identify those patients where maybe their situation is more acute or maybe their situation could be deferred later, such as someone who is newly diagnosed with prostate cancer. I think taking in to account all the radiology, all the imaging and whatnot can really help shape that discussion and help identify the right patients.

So patient selection I think is the first thing that we really need to focus on. Which are the patients that we need to bring in and which are not? And then once we identify those patients that you need to bring in, it's important to bring them in in a safe manner. And I think there are a lot of physical steps that every practice can take to ensure the safety of the patient and the safety of the staff and the providers who are providing care for this patient. One interesting development, which is kind of a silver lining of all this is the fact that we are being forced to become more comfortable and we are being forced to embrace telehealth into all of our different practices, whether it's teleradiology or teleconsult, whatever that shape or form might take. I think it's forcing us all to take a hard look and find ways to incorporate that into our practice. That will decrease the number of touchpoints which is our aim in today's COVID-19 environment.

Alicia Morgans: I completely agree and I think that many of our clinicians have really been embracing certainly multidisciplinary collaboration and telehealth and I appreciate your comments on that and I wonder how specifically can nuclear medicine physicians engage in telehealth with our patients with prostate cancer or other GU malignancies during this situation?

Phillip Koo: Sure. For nuclear medicine obviously it's very different from a medical oncologist or urological oncologist. I think the best thing that we can do from the nuclear medicine perspective, we start with the diagnostic piece. We should identify those patients that should come in for imaging and then maybe those that should not and I think that decision should not be made unilaterally. I think it's really important for the nuclear medicine or radiologist to speak with the referring physician and have that discussion on whether or not that patient can be safely delayed or not. If they can and the group is comfortable delaying that patient, then maybe that patient should be scheduled four to eight weeks later.

On the therapeutic side, nuclear medicine is playing a much greater role in the treatment of patients. In the U.S., radium-223 is a therapy that a lot of nuclear medicine physicians are giving. PSMA therapies are more prevalent across the globe. For someone who's currently in the middle of their course of therapy, I think it's important to finish out what you started. So if a patient is in cycle two of radium-223 or they're getting PSMA lutetium-177, it's important to finish what was already started before this COVID-19 progresses, if feasible.

And then for those where we're thinking about initiating new therapy, that's where I think that multidisciplinary discussion needs to take another level. We need to look at the comorbidities of the patient. We need to look at the risks of potentially exposing a patient to COVID-19 versus not. And again, that discussion is going to be different based on what city you're in, where your practice is located, what the current pandemic is looking like in your community. So I think with that discussion I think we'll be better able to identify those patients that we can safely start on therapy. But you also need to understand if you are starting therapy, you need to feel confident that you will be able to deliver six doses for radium-223, for example. So a very complicated discussion and I think that decision is best made a conjunction with our medical oncology colleagues and our urologists.

Alicia Morgans: I agree and I appreciate the emphasis on multidisciplinary care. I also think a lot about your leadership role at Banner MD Anderson in Phoenix and how you really direct not just the nuclear medicine group or the radiology group, but you have a lot of input and I think you direct the hematology/oncology division as well. And in this leadership role and please correct me if any of my attributions of your leadership excellence are incorrect, but in this leadership role, you have to care for many clinicians, physicians, academicians who are also trying to care for patients and who have their own stresses as they're trying to move forward in the era of COVID-19. And I'd love to hear your thoughts on that.

Phillip Koo: Sure, sure. So just to correct you, I have a peripheral oversight role for some of our medical oncology practices in one of our regions. But that being said, the biggest thing that strikes me right now, which is so inspiring, is to see how all of our teams are really stepping up. And I always say that for a patient, one of the worst days of their lives is when they're told they have cancer. And when they're told they have cancer, if we tell them that we can't provide you with the appropriate care, then the hope is gone. And what we're seeing across the country and across the world is the fact that people are stepping up to make sure our cancer patients have the care they need so they can beat cancer. Because COVID-19 is clearly a stress that they're having, but oftentimes the stress of cancer far exceeds the stress of being exposed or catching COVID-19. But when you see your colleagues and we see our colleagues in New York and the hard-hit areas really putting their lives on the line to take care of patients, it's inspiring. And I think we all recognize that in a lot of ways it's a duty and a calling that we have that we all took the oath for when we were in medical school.

But on the flip side, I think we need to really focus on how we support our physicians and APPs and we need to continue to find ways to make sure we recognize and provide the appropriate resources to get them through today and get them through the aftermath of what we are going through. And that is obviously a very complicated discussion and I'm not an expert on those types of mental health issues and wellbeing-type initiatives. But it clearly is a need and it's something that we shouldn't forget about as we go through this. So if there are ways that we could support each other, whether it be big or small, I think it's important that we all sort of band together because it's a global problem and it's going to require a global coordinated effort to get through this and to live through past this and thrive after this hopefully temporary event.

Alicia Morgans: I appreciate that. And I think that whether we have mental health expertise or not, and whether we are the clinicians on the front line or whether we are more in an administrative role, even acknowledging the stress and the struggle that people go through is at least a step in the right direction as we think about supporting these physicians and nurses and MAs and schedulers and certainly APPs, mid-levels, all of the folks who are really involved in the day-to-day. Because our patients are stressed, we're stressed and because we do our best to be there for our patients whenever they need us, our families are stressed, too. So, I appreciate that we're at least acknowledging that and we're trying to support them as an effort to at least acknowledge again before we necessarily have the tools to provide next steps. But we recognize that this is an issue.

So as you continue to move forward as a nuclear medicine physician and as a physician who cares for men and women, of course, many of whom are retired or are older just given your patient demographic in Phoenix, do you have any recommendations, any guidance that you can give the rest of us as we move forward in this unprecedented situation?

Phillip Koo: The only recommendations I have are to be thoughtful and we're going to have to make difficult decisions in this. But those decisions I think are made best when we actually have multiple experts and stakeholders at the table. So let's continue to promote that collaboration. Let's continue to work together because every situation is different. We talk about personalized medicine, we know every patient has their own unique sets of challenges and there are social issues that we need to take into consideration as well. So, that's something that we can continue to focus on. And again, make sure we can personalize this as much as possible.

And also the last piece of advice I have is just to stay positive. It's really easy to go down sort of this hole of negativity during all this crisis. You watch the news and everything just sounds like it's so terrible, which it is terrible. I don't want to minimize the fact, but I think there's hope that we are going to get out of this. We are going to be stronger. We are going to learn a lot of lessons from this pandemic and coming out of this if we don't take something positive out of this then it really is a lost opportunity. So I encourage everyone just to stay positive and it'll lift the spirits of everyone around you and it will really help us get past this and really be victorious over something that we know we can be.

Alicia Morgans: I completely agree and we will get to the other side. We all know that and we can all take heart in that. And as we do, I appreciate hearing from voices on the front line across the country and certainly internationally as well as we think about and share our best practices and our experiences to try to support each other and support our community as we move through this very, very, very unique situation.

Thank you so much for your time, Dr. Koo. And I wish you a very peaceful weekend and a good few weeks to come. Thank you.