Alicia Morgans: Hi, this is Alicia Morgans, GU medical oncologist and Associate Professor of Medicine at Northwestern University in Chicago, Illinois. And I am so excited to have here with me today, Dr. William Oh, who is a Professor of Medicine and the Chief of Hematology-Oncology as well as the Deputy Director of the Tisch Cancer Institute at Mount Sinai in New York. Thank you so much for being here with me today.

William Oh: Thank you, Alicia. It's my pleasure.

Alicia Morgans: William, we had talked a few weeks ago about what you were experiencing in the center of what's going on with COVID-19 in New York City. And you had so much to share both about your experiences as GU medical oncologist, but also what you were doing as the Director of a group to really try to help maintain everyone's practice across the center and of course maintain the safety of patients and clinicians. Things have certainly changed since we talked a few weeks ago, and I'm wondering if you can give us some updates on how things have evolved.

William Oh: Sure. Well, I think people are all reading the news, and we're happy that in New York City, I think we're past the peak. It's a slow decline, but we know that, for example, today across the six hospitals at the Mount Sinai health system in New York City, we had a 5% decline in our total census. It's about 1,300 patients. So it's still a substantial number. But we've had a sustained decline every day in the ICU and in deaths and admissions over the past week. So I do think, with the social distancing and what New York did to just basically shut down the city and the state, that we have successfully gotten past this particular peak.

In terms of what we talked about last time, we were really right in the midst of it, cases were rising and our cancer patients were getting COVID-19, and we were really urgently looking for ICU beds and shutting down a significant portion of our cancer program. Since that time, we really have made a lot of progress. First of all, the cancer program was never fully closed because cancer patients, in our perspective, is that they really can't all wait. Some patients were getting chemotherapy, some patients were in the midst of active treatments that could not be delayed. But in fact, a substantial proportion of patients we did reschedule. We converted to telehealth visits really dramatically. We're now doing hundreds and hundreds of telehealth visits a week in the cancer program.

And because we never really closed our outpatient practice, and because we sustained a reduced but persistent inpatient non-COVID cancer practice, we're probably going to be one of the first clinical programs outside of the COVID units to really ramp up. And that's actually already happening. We are decommissioning some of the COVID inpatient units and converting them back. And we're really... We have this huge backlog of cancer patients who need therapy, and we're starting to either bring them back in or continue these telehealth visits for those who do not need to come into the city at this time.

Alicia Morgans: So how are you able to do that logistically? At least, one of the things that our team has been talking about is that we have also paused a lot of the not necessarily elective things, but for patients who didn't necessarily need to start their chemotherapy now or for patients who could potentially have some period of time before they started their whatever, fill in the blank therapy, or had their surgery and those kinds of things. Are you anticipating that you will have more patients than your system is used to handling? Or do you have any suggestions or advice for us as we try to get all of those patients who were delayed back on track, given the limitations that we have in terms of keeping waiting rooms hopefully rather empty, and just being cautious about social distancing even in the clinical setting?

William Oh: Yeah, I mean, this is a difficult question to know the right answer to. I think everyone's going to slowly start to figure this out for themselves. I know my May schedule looks really packed right now because we rescheduled a lot of people from March and April. And many of those that are currently in-person visits, we have not automatically converted them to the video visits as yet. But we may be doing a mixture of both. GU oncology, for example, there are many people who we have been delaying their androgen deprivation therapy. There are some patients of mine who have a slow rise in PSA, and we've been sending them to local labs on Long Island or New Jersey because they obviously don't want to or even need to come into the city necessarily to see me. We can do a lot of things over the telephone and through video.

But I think that, as we all know, there are people who really need to be seen, whether they need some kind of surgical procedure. There are many probably underdiagnosed or undiagnosed patients with cancer, but also patients who really urgently need treatment because they have advanced cancer and will need to go on an immuno-oncology drug or chemotherapy. In that case, we have developed a whole protocol for both testing each of these patients before they start chemotherapy or IO therapy before each cycle. And we're also really looking at how we start to safely bring these patients back in.

Our expectation is that it will ramp up, but that it won't be at the same volumes, or certainly, our waiting rooms are not going to look at all the same as they did before the pandemic started. But I think that our strategy is to really respond to the situation on the ground. Right now, when I go to clinic and I'm seeing half the number of patients or a quarter of the number of patients that I normally would see, the waiting room is relatively empty. But I think in the next few weeks, in the next month, while New York starts to lift some of its restrictions, people are going to start to come back out.

Alicia Morgans: Yeah, I'm sure that they will, and I'm sure new patients will be diagnosed and we'll have to certainly treat them. And one group that I think about, because we've had to treat several during this pandemic, and we continue to treat them, is testicular cancer patients. These are patients who need chemotherapy when that's part of their treatment paradigm and, really, they can't delay that chemotherapy. So just thinking about that population as reflective of any other population that may need chemotherapy, how are you using testing to keep them safe during chemotherapy? You mentioned that you're thinking about doing testing before they start their treatment.

William Oh: Yeah, we've already implemented this policy at Mount Sinai. Basically, patients who are going to start each cycle of chemotherapy or immunotherapy will have to get a COVID PCR test and a SARS-CoV-2 test to rule out, even if they're asymptomatic, to rule out that they aren't an asymptomatic carrier. Logistically, this is not easy because we don't have a test that can give a result yet in an hour or two. It takes 24 hours for us to get a result. So we are having patients come to testing centers, either within our health system or in Manhattan, to get tested before they start their first cycle of treatment and with each subsequent cycle. As the testing becomes easier, as point of care tests become available, when we might get a result in a few hours, and as we learn more about serology, for example, and the ability to really know who's been exposed and may be asymptomatic, I think this should get easier.

But right now, our goal is to really take the data, which suggests the patients getting chemotherapy who were also COVID positive are at greater risk, and at least considering that in the decision making. Obviously, a testicular cancer patient, if he's a younger man who may be at less risk and is going to otherwise die of his testicular cancer, even if he's COVID positive, there may not be much you can do except to go ahead and treat him. Whether you can delay a week or two, that's different from a man in his 70s with prostate cancer and a slowly rising PSA, where there's a lot of ability to defer immediate treatment.

Alicia Morgans: I totally agree. And I appreciate your insights and experience on that. And I wonder as you've treated patients in the heart of Manhattan in the last few weeks, how have your patients done? Have they been able to get chemotherapy or their immunotherapy or whatever their treatment is and do relatively well? Or are you seeing catastrophe in your patients? And the reason that I ask this is because some that we've talked to in some of the research projects that I've participated in with registries, for example, have suggested that absolutely there are increased risks for any individual with a comorbidity, but that patients with solid tumors of GU malignancies actually seem to do okay, as long as we are monitoring and managing them really thoughtfully. And so I'm just curious how your patients are doing.

William Oh: Yeah, I mean, I actually agree with that. I mean, I think that we have not seen this population. And you can imagine, they're older men. Older men are supposed to do the worst of all categories of patients with COVID-19 disease. And we have not really seen that. And obviously there are a lot of hypotheses going around. Maybe androgen deprivation can be somehow protective for biological reasons. But we have really not seen those kinds of very bad outcomes with cancer patients that we were worried about.

Now, that said, I think some of the larger cohort studies that are now coming out from New York, including the group at Mount Sinai, cancer does not seem to be a strong risk factor for poor outcomes. We're seeing a lot more cardiovascular risks. Besides age, we know also that African Americans and Hispanics are at greater risk of getting the virus, although we have some data at Mount Sinai that suggests that after they get the virus, there's no difference in outcome by races, which suggests that maybe there's no biological difference. It's really more of a socioeconomic difference in terms of who's at risk of getting the virus.

So hypertension, diabetes, those risks seem to be more prevalent than at least the history of active cancer. So we're encouraged by that. I think the pathogenesis is still very, very unclear. We do know, for example, that we're seeing a lot of thrombosis, microthrombi, maybe in the pulmonary vasculature. And we know that cancer patients are very at risk of being hypercoagulable. So you'd think that those two things would also not really jibe well. But at least for now, the large cohort groups in New York where there've been thousands and thousands of patients in the different large health systems, cancer does not seem to rise very high as one of the most predominant risk factors.

And I don't think that means that we as cancer doctors can just willy-nilly go treat everybody. I think that's obviously not what I'm suggesting. It's really more that for patients it's really about risk stratifying their cancer relative to the risk of COVID-19. There's a psychological part here, as you're probably seeing it also, Alicia, there are some patients who should get therapy and still don't want to start it, and we're trying to convince them that we can safely treat them.

But I do think that as the cases continue to go down, and if we can make sure to reach out to our patients and convince them that we can safely treat them. We're social distancing with the masks, with screening. As patients walk into our outpatient cancer treatment center, people will start to feel more reassured that they can go back to the business of treating and hopefully eradicating their cancers.

Alicia Morgans: I think that's absolutely true. And it's going to be important, as we try to move into this phase of new normal and continuing to treat patients and helping them, as you said, get over the psychological burdens that they face, knowing that their cities are shut down and they're not going out to go to work. And all of the changes that are in their day to day layered on top of the cancer diagnosis can be overwhelming, I'm sure. So it is up to us to try to help them understand that risk-benefit ratio. And as we get more data, that will be easier too.

And as we wrap up, I just would love to hear your thoughts on where we're going in terms of clinical research now that things are continuing to evolve with COVID-19. You are very heavily involved in that, both as a GU medical oncologist and also, of course, as the Chief of your group. Oncologists are always searching for new ways to do things better, improve patient outcomes. So where do you see things going, and how is that evolving?

William Oh: Well, our research program has also, like many other places, been really significantly reduced. And we've all become kind of COVID researchers, at least in the short term. And I think you're right. Cancer researchers have a lot to offer in this setting. We have a big infrastructure and NCI-designated cancer centers. And we have a lot of knowledge about how to approach these problems systematically, both in large retrospective database analyses but also prospective trial design. And we have been very, very active in this, even in non-cancer patients.

But over the next few weeks, we anticipate that we will start to pull away from the non-cancer patients, and we want to repopulate and renew our cancer research program because we know that that's really critical for outcomes in cancer patients. We are developing protocols in COVID positive cancer patients, but we are really wanting to very much open up the cancer research protocols that we've had all along.

So it has been a repurposing. Our faculty have wanted to help. It's been really interesting to work with faculty who have been put into this position in cancer faculty, and also the fellows, who also want to help. In that regard, I think cancer doctors have been really critical for that kind of research approach that I think is going to be needed to ultimately defeat COVID-19.

Alicia Morgans: Well, that is certainly hopeful, and I agree that it's wonderful that the infrastructure of clinical trials and oncology has been one that has certainly served as a good example for others and also can be leveraged while we deal with COVID-19. And I look forward to hearing from you again and hope that you and everyone you work with and all of your patients stay safe. Thank you so much for your time.

William Oh: Thank you, Alicia. You too, stay safe.