Alicia Morgans: Hi. This is Alicia Morgans, Associate Professor and GU medical oncologist at Northwestern University in Chicago, in the United States. I am so honored to have here with me today, Professor Tom Powles, who is a Professor of GU Oncology and the Director of the Barts Cancer Center in London. Thank you so much for joining us today.

Thomas Powles: Alicia, thank you for inviting me.

Alicia Morgans: Things are not normal recently and we wanted to talk about why that is and how COVID-19 continues to evolve and impact your cancer center and your practice. Can you give us some updates since we talked last?

Thomas Powles: Yes, I think things are changed a lot in the last few weeks because I think the perception of the future has, for me and I think for our cancer center and for London and probably for the world, is different. I think we've probably seen the back of what was the first wave of this, which people are talking about. Although when you look at the data, you can still see obviously more deaths than we would like. You can still see the incidents being high. I think it's apparent that the ITU departments and the emergency departments and the capacity of the health service have coped, which wasn't always the case from a global perspective. And clearly, when we last chatted, we were concerned that London would go the same way as Northern Italy and Madrid and really struggle. And while there were some typical days, I think that the reality is that that first period has passed and we now have the capacity.

And what we're now doing is say, well, what does the future look like? And I think there were two important things for that. Number one is, I don't think the virus is going away. And I think that the minority of the population has been affected. And I think that the cancer patients that we treat remain at a higher risk. There is still the likelihood that the infection will come back. And when it does come back, I think we'll be better prepared. And I don't think we'll have health care threats from those collapsing. But I think cancer patients have an increased risk if they were to catch the virus of coming into harm's way.

And the last piece is, it's apparent that there aren't any current treatments or vaccines to the problem. And we've made the assumption that it's going to be here for a year and there will be a roller coaster ride of good months and bad months. But, the patients who we're looking at with cancer require treatment. There are 165,000 cancer deaths in the UK every year. While I suspect that will be many COVID deaths, I suspect the cancer deaths will still outnumber the COVID deaths at the end of that time. And we know that if we don't treat patients, more patients die and they die more quickly and with worse symptoms.

We can't put off or postpone treatments that we need to do any longer. And the phrase that I'm using with my colleagues is, if not now, then when? If you don't want to start treatment today or you don't want to do your operation today, do you think it's going to be better in three months' time? And the answer to that, it won't be better in three months' time. Heaven forbid it might be worse because we might be during a second peak, which we'll have [inaudible].

From a cancer perspective, I think it really is a case of saying who are the patients that we need to treat in this new environment? What is the risk-benefit ratio? For example, I'll give you an example of something that I'm involved with. I treat patients with bladder cancer. Frontline chemotherapy probably doubles or triples your overall survival in that setting. It's only a difference of six or eight months, but if your life expectancy is only a year, or a year and a half, patients will want to start therapy. And we've started the treatment on those patients. Regarding immune therapy, there's currently no data to support the fact that patients die more quickly if they've had immune therapy or to increase risks. We've had five COVID positive patients on immune combination therapy. All of them have been symptomatic, being admitted and all of them have survived. I don't know how many patients on immune therapy who have had the infection, who haven't tested positive. And we're going to hear more data about that in very near future.

But as it currently stands, we feel immune therapy is also safe, and obviously targeted therapy is safe. I would say that our approach to cancer at the moment is those patients that need treatment we treat, but let's take the example of adjuvant chemotherapy for bladder cancer. No real proven benefit, so we're not doing that. Let's talk about chemotherapy for prostate cancer. Well, given a choice between enzalutamide and abiraterone and chemotherapy, we'd obviously give enzalutamide and abiraterone.

Just to summarize what I've said, we're in it for the long game. If not now, then when? We're no longer postponing treatments, we're getting on and doing the treatment in front of us. Our risk-benefit ratio of each treatment changed. But, remember the cancer patients, the majority of which need treatment and we're continuing to pursue that.

The last piece I wanted to say, I had a conversation with a patient of mine, called Larry, this morning. He's just progressed on one line of treatment, his life expectancy is probably about 12 months now. And he'd asked me if he should be in lockdown. I said to him, listen because he's 70 and he's got cancer, according to the advice he's a high risk. The problem I said with him is, you can go into a period of lockdown, but it could be a year and that's probably your life expectancy. And you need to work out the things that you want to do and you just need to re-change your risk-benefit ratio. Because spending the rest of your life in an isolated room, he lives by himself or in a flat. Obviously it's not a quality of life. I just think my mindset's changed to say we're living with this now, we're living with increased risk, let's get on with the treatments we need to do. Let's assume things will be worse days and better days, and really try and focus on what individual patients need.

Alicia Morgans: I think that is so helpful to hear and really interesting because I think as the US is following along and maybe not in a point where we universally have really even peaked, plateaued, and are starting to trend down, for most of us at least. We are not, or I have not heard, that most centers are saying if not now, then when? But I think that that's in our future because there was actually a rush in some centers to try to do a bunch of procedures prior to when we thought that this would become a larger problem. Knowing that we would have some downtime, while we, of course, are focused on treating COVID-19, but I have not yet heard folks in the US talking about, "let's move forward". At this point, we've got to catch up on all of these things and we recognize that more waves, at least maybe a wave in the fall, if not more, may be coming.

It's really interesting to hear your strategy on that and I think that we all will be moving in that direction. How do you do that in a way that keeps health care workers and uninfected patients safe? Or are you testing to make sure that when patients are admitted to the hospital that they are negative? And waiting for positive patients to become negative? Are you performing procedures on negative patients and then just monitoring them in a COVID unit? How are you doing this logistically?

Thomas Powles: There's no disadvantage in testing. And I think that the reality is, the reason why there's less testing that's ongoing, and the PPE story is not that dissimilar, is to do with the amount of resources. The UK has not tested as many patients as Italy. Certainly not as many as the US or Germany, indeed. I think the principle of testing the cancer population, tracing is important. We're not currently in a position where we can test all our cancer patients regularly. Whether or not in six months' time, we're in a position where there are reliable antibody tests and reliable tests looking for the virus itself, whether we're there, I think we will be in six months' time. And I imagine that landscape will change.

Looking forward I think we'll be contact tracing much, much better because it's going to be crucial. I think we're going to be testing much better. And we'll know a higher-risk population that we can isolate. I think keeping the hospital clean is really important. No friends and relatives. Patients and carers are allowed in the hospital, clearly. There are exceptions to that, dying patients need to see their relatives and et cetera, and we're all supportive of that. But bringing two or three friends to an appointment is not right. Also, we're doing tele clinics, it's probably 70% tele clinics, 30% face-to-face. There are upsides and downsides of that, which I won't go into today. And then, of course, there's screening on the doors of the hospitals. You can't get into the hospital without washing your hands, saying why you're there. Keeping the hospital clean, reducing the footfall is really important. That's the first thing.

And I think the second thing is, there has been a big impact on cancer patients. And I don't know if this is true in the US this year. But essentially, what's happened in the UK is the patients are not coming out of their homes and are not going and getting diagnosed. And we've seen a 70% drop in our referral pathways, a huge fall. And that's because patients have been told to stay at home and they clearly see depictions on television and how chaotic hospitals are. And they see if they go into a healthcare environment, they're likely to pick up infection.

Coming back to the "if not now, then when?" debate is, I would expect in the US and in the UK, our sensible patients with what they deem as relatively mild symptoms are not going to the hospitals. And as soon as these lockdowns are lifted, the first thing they're going to do is, if they've got blood in their pee, they'll be going to their doctors.

And I'm expecting a real increase in cancer referrals over the next 12 weeks. And I suspect it won't start for another four to six weeks. And that may coincide, heaven forbid, with a second peak in the infection. And we need to be very mindful of how we build really safe hospital environments, how we change our pathways, and how we get patients in and out of the hospitals, safely. In their knowledge, we have to treat them.

I had a conversation with some of our gastroenterology teams recently and some other teams. Different groups feel differently about risk. But clearly, if you've got a GI or a breast cancer, you're going to want to go in and have that operation done successfully in a short period of time for the potential for cure. And particularly if you're younger rather than older, your risk is relatively modest. If your five-year survival from a cancer will take a 10 or 15% hit because you're not having a procedure or a treatment that you need, that risk is probably greater than COVID, speaking frankly. And that's an important conversation and patients simply don't know that data.

How can patients be aware of the mortality of COVID and the mortality of cancer and make a sensible decision? Just phoning your patients up and asking them what they want. Obviously, they're going to say they want to stay and isolate themselves. If you say that you've got a 30% chance of coming into harm's way in the next two years if we do nothing, the patients are all in front of you, in front of the clinic. I think empowering the patient with the information, making team decisions about which groups are right to treat is important. And the last thing I want to say, Alicia, around this, I know I'm talking too much, is that the guidelines that we're getting from pretty much everyone, including some of the guidelines I've written are four to six weeks behind what's really needed on the ground floor. Because, by the time you've written them, they've been peer-reviewed and they've been published and edited and reappear, that timescale is way behind.

Six weeks ago my mindset was completely different from now. I didn't know that the health system wasn't going to collapse. We were saying to all our patients, just try and not get the infection. My mindset now is completely different. The direction of our cancer center, it's completely different. And what I say to healthcare professionals is work together as teams. Yes, of course, take advice, but you have to treat what's in front of you in the environment you're in, in the future. Because I suspect when the second wave hits the UK, the US will be in a slightly different place and certainly different parts of the US will be in different places. And if it's bad in New York, and it's not bad in Virginia, if Virginia copies what New York does and it's three months continually out of step because of New York's guidelines, what will happen is you'll continue to be treating your patients during the height of the pandemics to come. So it's really important we empower doctors on the ground to look after their patients.

Alicia Morgans: I completely agree. And I think that the strategy of trying to understand the tempo of the illness where you are and understand best practices, given that environment is going to have to be the one that ends up leading the way and is a really good message, I think to everyone. It's also a good message to hear that as things do simmer down a little bit with this in terms of the infection, and as we gain more information about what actual infection rates are and what actual mortality rates are for patients with cancer in the UK and in the US and wherever we are, this will help to inform those treatment decisions that we have to make, knowing the risks that we do know for an individual's cancer. I think those are really important messages and certainly translate beyond the UK to all of us as we're trying to work through this.

And you're never talking too much, so never think that. 

Thomas Powles: I talk a lot.

Alicia Morgans: You don't. You say very meaningful things. And as we wrap up, what is your final message or recommendation for folks around the world who are trying to continue to provide the best care that they can for their patients with GU malignancies?

Thomas Powles: I think my message is two- or three-fold. I think the first thing to say is that I hope and we all hope that the first wave of infection has, as it passes, we've learned from it. I think our healthcare systems will be better prepared. And I think that making pathways which allow cancer patients to bypass high risk of infection is really attractive. For example, instead of unwell cancer patients pitching up to accidents and emergency departments, they should be protected and pitching up to cancer type wards. I think having COVID-free environments or relatively free, to treat cancer patients, makes a lot of sense. Because I do think that cancer patients are at increased risk. That's the first thing.

I think the second thing is that it's apparent, and we've had this experience, as you treat the patients that are in front of you, while the risk-benefit has changed a bit, the majority of treatment should continue. And that includes surgery, target therapy, immune therapy, hormone therapy. But the risk-benefit ratio may have changed or has changed a little bit. And therefore, some of the standard treatments from before may be slightly different, and that discussion needs to happen with the patient.

I think the last piece that I'd say is the patients who I see are very scared and the perception is that they will come into harm's way when they get COVID. And they assume that when lockdown stops, their risk stops. And I don't think that's correct. I think number one is, it's still the minority of patients. Even for cancer patients who come into harm's way from COVID, but many patients will come into harm's way from cancer. And that balance needs to be addressed, number one.

And number two is, I don't think in three weeks' time this problem would be gone away. I suspect it will be here for 12 months. If you're thinking of saying, don't worry, let's do it in three months' time. My concern around that is, you may actually find your healthcare system is now a less good position in three months than it is now. And actually building up cancer numbers over a period of time, will put more stress on health care professionals.

My feeling at the moment is, work out those patients that need treatment. Treat what's in front of you and keep your patients as safe as you can.

Alicia Morgans: I think those are excellent messages, very rational. And I hope this inspires all of us to start in our pivot to really thinking about how do we start finding a new normal. Now that COVID-19, the initial shock, hopefully, is I'm wearing off our systems are adapting. And we need to continue to adapt to get back to some routine that will be our normal way forward in the future, understanding that this is not going away anytime fast. Thank you so much for your time, for that inspiration, and for that encouragement for each of us to continue to weigh the risk-benefit ratios with our patients so that we can take the best care that we can.