Transcript
My name is Axel Grothey. I'm a medical oncologist at West Cancer Center in Memphis, Germantown, Tennessee. I'm the director of GI cancer research here at the center. Of course, we're all affected by the COVID-19 epidemic, which has not spared any part of the country, and now it really presents a huge challenge how to manage oncology patients at the time of this crisis.
Let me talk a little about telemedicine, what we've done. Right now, at this point in time, we are in the fortunate situation that insurance providers have adopted the telemedicine approach. We can charge in this, we can bill patients and insurances for telemedicine, which I think is an amazing step forward. I hope this is one of those things, which will keep after the crisis is over.
I actually enjoy these visits. In particular, since you see patients in their home environment to some degree, and it adds a different part of the story to it. Of course, you can't really do a full physical exam, obviously, but you get a lot of the patient's appearance. You get a look at rashes. You can look at swollen legs, etc.
I think you get a lot of information out of it, and it allows patients to talk to a provider in a safe and better environment than if they just come and you need to drive to an appointment, be potentially exposed to healthcare threats, and actually also waste more time during the day because we can schedule appointments really like a routine appointment, then see patients in the home environment. So I truly enjoy telemedicine, and I hope this will stick around once we've gone through the crisis.
Now new patients, of course, cannot yet be seen through telemedicine. That's something that we're working on being set up.
Once we have done that, it would be an amazing way to look at second opinions, across the country, across the world, to really change the way we handle referrals, etc. I think this can eventually help us provide better care.
So let me talk about individual treatment decisions we've made for patients who are on active therapy.
Cancer doesn't wait, as I said, for corona. Cancer is an immediate need, and active cancer therapy should be provided in patients who need it. Now, we can make modifications of the therapy in order to lower, let's say, the immunosuppressive effect of, for instance, chemotherapy.
Some of the regimens can be spread out, whether we give FOLFIRI, for instance, every 2, 3, or perhaps even 4 weeks in order to just control the cancer. That's something that can be discussed and can be adjusted according to the aggressiveness of the cancer that we're facing and the individual needs of patients.
I've always routinely deleted bolus 5-FU from, for instance, FOLFOX and FOLFIRI to lower the risk of patients getting their neutrophil counts affected. We have been using more growth factors lately just in order to make sure that patients are not as immunocompromised as before, if they needed to keep on therapy.
We've also switched some of the regimens from IV, for instance, 5-FU to oral capecitabine. First of all, capecitabine by itself as a continuous treatment is less immunosuppressive as, let's say, the IV treatments that we see.
On the other hand, it allows patients to get treated at home. They don't have to come into a healthcare facility. That alone can reduce the exposure to the virus, and the healthcare provider can space things out better in their clinics.
Some decisions were made in order to hold off on treatment completely for some time and give patients a complete chemotherapy-free interval, which can be the right choice for select patients.
I had a patient, an elderly patient actually, who had an almost obstructing esophageal cancer, squamous cell cancer. We discussed an 82-year-old patient, likely lined up for definitive radio-chemotherapy, who can't swallow anymore, this patient really presents an unmet need. We need to treat this patient without any delays. We managed to actually do that.
It's a very individualized decision for every single patient in this shared decision-making process, acknowledging age, risk factors that patients might have in this time of crisis.
When we, in everyday practice, deal with our patients and have to make a decision, for instance, based on, let's say, progression of disease, patient needs to move from first to second and second to third-line treatment, there are several challenges, of course.
First of all, we try to limit the direct patient-physician interaction. Telemedicine comes into play. In delivering bad news, like, "You have a progression of liver metastases or lung metastases, you need to change therapy," it's not always easy to work through telemedicine. A personal approach is better.
Now, we still do that. We do move patients from line to line of therapy based on scan results, etc. We've not shut down our chemotherapy unit. We might delay the onset of second or third-line treatments, switching therapies based on the aggressiveness of the progression that we see.
I do believe that our cancer patients still deserve optimum treatment, of course, because their cancer is real. It's an unmet need for them. It's a life-threatening situation, whereas the COVID-19 potential infection is only hypothetical. It's a real risk, but it's not there yet for them, not as immediate as their cancer.
