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Mar 27, 2020

In this episode, we discuss the coronavirus pandemic and its impact on patients with cancer with Dr. Gary Lyman, of the Fred Hutchinson Cancer Center, in Seattle, Washington. Dr. Lyman discusses the massive challenges facing oncologists and other health care workers in his state - one of the epicenters for coronavirus infections - and around the world, and a pioneering effort to create a global COVID-19 Registry to gather data and information about treatment approaches specifically focusing on the impact of the virus on patients with cancer. 



ASCO Daily News: Welcome to the ASCO Daily News Podcast. I'm Geraldine Carroll. In today's episode, we're discussing the coronavirus pandemic and its impact on cancer patients with Dr. Gary Lyman, a medical oncologist at the Fred Hutchinson Cancer Research Center in Seattle, Washington, where he is senior lead for health care quality and policy at the Hutchinson Institute for Cancer Outcomes Research. Dr. Lyman is also professor of medicine and public health at the University of Washington School of Medicine.

We'll discuss the massive challenges faced by oncologists and other health care workers in his state, one of the epicenters for coronavirus infections, and around the world. We'll also look at a pioneering new effort to create a global COVID-19 registry to gather data and information about treatment approaches specifically focusing on the impact of the virus on cancer patients. Dr. Lyman reports no conflicts of interests relevant to this podcast. Dr. Lyman, welcome to the ASCO Daily News Podcast.


Dr. Gary Lyman: Thank you, Geraldine. It's a pleasure to be with you despite these very difficult circumstances that we and so many in this country and worldwide are facing.


ASCO Daily News: Well, Dr. Lyman, how are you doing


Dr. Gary Lyman: Personally, I'm doing well. Of course, as you point out, we have been, at least until now, the epicenter of this infection, this epidemic, pandemic in the United States. The first case that was identified was here in Kirkland, Washington, where I sit at the moment because we are not, unless we're seeing patients, not working from the institute. We're working remotely. I'm about two miles from the wellness center, life care center where the first patient was identified in the United States. And of course, there has been in many, many cases, both among the residents and the staff there and this, of course, now throughout the state.


It's a very stressful time for all of us trying to deal with both personal protection, public awareness, and, of course, the clinical challenges in general, but recognizing that cancer patients who are on treatment or have completed treatment and may be more vulnerable have a very high degree of anxiety now. And we're trying to do our best to help them, comfort them. The real heroes in my mind are those on the front lines, so many of the physicians, nurses, other health care providers and support staff that just face both personal risk and the stressful challenge of helping patients through this pandemic at the present time.


ASCO Daily News: Well, your state was the first region of the country to be hit and, as you say, has suffered many deaths. What have been some of the most difficult clinical challenges? What have these past weeks been like?


Dr. Gary Lyman: It's been very difficult. Cases have been reported in 184 of the 195 countries in the world. In the US, as you know, things continue to rise in terms of incidents. Washington state, as you say, and, in fact, this very county and town reported the first case of COVID-19. Many other parts of the country are now beginning to exceed the experience here. New York state and New York City in particular have. Their rates have just escalated as testing has come along.


Of course, the problem globally is enormous, and ASCO and our research colleagues throughout the world have been in close contact with us and us with them. I can say here at the University of Washington and the Fred Hutchinson Cancer Center and the Seattle Cancer Care Alliance, we're just beginning to see the rapid assault of this problem on our health care system, which we're anticipating being stretched, if not overstretched, in terms of that capacity in the next couple of weeks.


The challenges we have, both here and I think everywhere where this epidemic is just so pervasive, are a shortage of anticipated, if not already, shortage of beds, particularly ICU beds, respirators, ventilators, and particularly critical need of protective equipment for providers at all levels. You've all heard of the circumstances where protective equipment is being reutilized, is being improvised. The providers on the front lines that I call my heroes are putting their very lives and their families as they go home at risk by doing what they were trained to do, which is to comfort and heal the sick, in this extremely difficult situation. And I have to praise ASCO and other professional organizations for really trying to rapidly increase public awareness of this, provide resources for both providers and patients to go to to gain as much knowledge and access to needed resources as possible.


Clearly, we were kind of late to the game as a country. We need far more federal national coordination of these efforts, but the states have stepped in, including Washington state, Governor Inslee, and the local health care officials. We've just been told to, of course, stay at home, as have individuals in New York state, California, and many other states throughout the country. Of course, vital services, health care, food services, and so forth remain active, and those workers, of course, are vulnerable because of continual contact.


But I think we're all in this together. And right now, I see Washingtonians-- and we do think this is hopefully beginning to bend the curve here, maybe not so much in New York and some other areas yet, that the social distancing, the increased care in terms of hand washing and avoiding exposure when you're ill. Getting testing has been a real challenge as you know.


We really don't even know. The numbers I quoted for the US, anyway, really probably under represent the true magnitude of this problem. So the coming weeks and months are going to be challenging for all health care providers. And again, cancer patients, either on treatment or having completed treatment, perhaps immuno-suppressed, are among the most vulnerable of the population at risk for both getting the virus as well as experiencing serious, life-threatening complications from this virus, which we know can be extremely serious or even fatal.


Well, we certainly hope that Washington state is beginning to bend the curve, as you say. Let's focus on those immuno-suppressed patients for a moment. In the case of cancer patients, by giving patients chemotherapy, are we making these patients more exposed to the complications of the virus? And what are the steps that can be taken to mitigate this?


Yes, and well, you highlight one of the most challenging issues for oncologists as well as cancer patients at this time. And that is whether to initiate or continue chemotherapy that we know in many instances is immuno-suppressive and in addition to the cancer, which, of course, can have its own risk factors. And this is often an older patient population with other co-morbid conditions-- heart disease, lung disease, and so forth. This is, as I mentioned, a very high-risk, vulnerable population.


So whether to add to that risk by initiating or continuing chemotherapy is a critical question that needs to be discussed with each patient's oncologist and decision made that's appropriate for the patient. It is a personal and individualized decision. I think we all recognize this there's not a "one size fits all" for this question.


There are patients with cancer where the cancer is an immediate, life-threatening risk to them, and without treatment, the risk from the cancer are probably far exceeds the risk of acquiring the virus despite the immuno-suppression. On the other hand, there are certain therapies, some adjuvant therapies that are being given to add percentages to the patient's the long-term outlook where that long-term gain may be offset by the short-term risk of acquiring the virus, particularly, again, in the older or more vulnerable cancer population.


If the risk of acquiring the virus is more than the 1% or 2% of the overall risk or if the risk of serious complications or mortality is in 5%, 10%, 20% range as some of the China data would suggest for some of these populations, that short-term high risk may be greater than the long-term gain from chemotherapy. So we're asking oncologists and ourselves to appraise each patient's personal risk from the cancer, their personal risk of acquiring or having serious complications from the virus, discuss it with the patient, and find out the appropriate balance of benefit and harms that matches the best for the patients.


I will say, I think there are many patients getting adjuvant therapy as I said for early-stage disease where the treatment probably-- the better part of valor is to delay chemotherapy at this time. That may pose some long-term risk, but it's probably fairly modest compared to the short-term risk if they get seriously immuno-compromised on treatment and acquire the virus. So again, and patients will have concerns whether they're more concerned about the short-term risk from the virus given their situation or the long-term risk from the cancer. So there is a shared decision making that has to go on on a patient-by-patient basis.


There is the added concern here, which, of course, patients on treatment with chemotherapy or other systemic therapies for cancer almost always need to come in for that treatment. And of course, that means they may be around or exposed to other patients, other individuals who may be exposing them to risk.


Unfortunately, we're learning more and more that perhaps as much as half of the exposure that occurs may occur from patients without symptoms or without significant symptoms and, because testing has been so difficult to get on a broad scale, that patients may be exposed to the virus without even knowing it until symptoms arise in their own case. So I think, again, a discussion is needed and appropriate action for each patient, but it is important we find that balance because the risk is real. And the risk is increased.


We're very confident. Data out of China-- there's not a great deal of data on this, of course, for cancer patients, which is one of the reasons we're starting this national and soon-to-be international registry study. But the limited data we have out of China is that cancer patients are probably somewhat greater risk of acquiring the virus and particularly at greater risk for serious complications from this. And until we have more data that says otherwise, I think we need to balance that risk, as I said, with the potential benefit from administering systemic immuno-suppressive therapy.


ASCO Daily News: So until we have more data, have the protocols changed at your cancer center for the patients and the people who work there? How do you protect patients from infection, since those receiving chemo infusions and health professionals who are drawing blood, for example, make social distancing quite a challenge?


Dr. Gary Lyman: It certainly does pose a challenge, and I think every institution, including here, are trying to adjust for it. Of course, as you said, if you're drawing blood or starting an IV and administering systemic therapy, you can't completely distance yourself physically from the patient. So of course, the staff are fully trained on protective measures for themselves and the patient. We do distance patients, both in the waiting area and in the treatment areas, as much as possible.


Follow-up with patients-- if it doesn't require an actual visit to the clinic, follow-up can be done remotely. Of course, we're doing a lot with telemedicine, but that, of course, doesn't translate into a situation where a patient's actually receiving systemic therapy on a given day.


The protective equipment, as you said, has proven to be a challenge. I think we're dealing with it reasonably well at the moment. But as the numbers increase over the coming weeks, we really will need more and more both local, state, and national resources to make sure that the staff and, in turn, that our patients are fully protected at the point of contact, the point of care.


So adjustments are being made. Again, as I said, for many patients, that discussion that I mentioned a minute ago has resulted in patients feeling they want to or should delay their treatment until the peak of this is over, so the numbers hopefully will be somewhat lessened. That will allow more social distancing and more protection be offered to those patients who are most in critical need of proceeding with their cancer therapy.


Elective surgeries are being canceled, which has a dual benefit of both freeing up the operating rooms, in some cases, to be used for intensive care purposes, but also for preserving the critical need for protective equipment, which would otherwise be used for those elective surgeries. This has not been universally applied around the country, but certainly, we've been doing this here. And many other major institutions have said, if your procedure is not an urgent one, if it's an elective one, it can be done later. Put it off so we can preserve the resources that are limited and going to be stretched even more in the coming weeks for those patients who are most critically at risk.


ASCO Daily News: Right, so let's focus for a moment on the global registry that you spoke of earlier. So to better understand the scope and severity of the COVID-19 infection in patients with cancer, a consortium of more than 30 cancer centers and other organizations have come together under the auspices of the COVID-19 and Cancer Consortium, abbreviated as CCC19. And they've launched a survey tool designed for health care professionals to share data and outcomes about cancer patients who have COVID-19 or are presumed to have the virus.


So this approach is modeled on a case study of the Colorado wildfires and the devastating 2010 Haitian earthquake, which found that disaster managers across the world can actually swiftly benefit from crowdsourcing available information. So can you tell us about this and how the survey works?


Dr. Gary Lyman: Yes, and of course, as you allude to, this is a grassroots effort that sprung up very rapidly. A number of us throughout the country were trying to find how can we begin to track and then better understand the impact of COVID-19 on cancer patients. An opportunity arose, led by Dr. Jeremy Warner at Vanderbilt University, which is the home for REDCap, which allows for remote entry of data on a national and global scale.


We established a steering committee, and as you point out, we now have more than 30 institutions either beginning to accrue or awaiting IRB approval. We're hoping here at the Fred Hutch and the University of Washington and Seattle Cancer Care Alliance to have our approval today in an expedited fashion. I have a great team here that, in addition to me, includes Dr. Nicole Kuderer, Dr. Ali Khaki, Dr. Petros Grivas, Dr. Andrew Cowan, and Dr. Margaret Madeleine.


We've put together a protocol to this. Interested individuals can go to the website and review this. We're basically capturing in this important information in a de-identified fashion that can help us understand better not only the frequency of this problem throughout the country. And again, as I said, even international colleagues are exploring participating in this, from Italy, Spain, France, other countries.


We capture the patient demographics, the information about their underlying cancer, their exposure and risk for COVID-19, and what is being done in terms of a treatment of the virus as well as their cancer treatment. And of course, eventually, it would be more of a look at outcomes.


This has clearly been a very fast-track process. Most institutions are either exempting the protocol because it is de-identified or fast-tracking it through the review process because we realize that time is of the essence. Things are evolving rapidly. We want to have this tracking and capturing in real time what's happening to these patients.


The primary goals here are both to script or to find out all the details around these cases, and then eventually, as the numbers accrue, perhaps develop some predictive modeling to identify oncologists and public health officials to better predict when patients are at risk with cancer for developing serious complications down the road. Information is power, and we believe this will provide important information.


And we do anticipate a very rapid accrual to this. We've already entered patients into this registry, and as more and more institutions come online, we think the numbers will go up quickly. And we will be continually monitoring this for red flags, information that should trigger further study of the COVID-19 in patients with cancer and why they might be a particularly high risk and what we begin to do about it.


We also anticipate-- of course, we're hoping-- that there'll be treatments coming along. There certainly are clinical trials being launched to explore the potential efficacy of a whole range of therapeutic options that have been proposed. We need clinical evaluation of these. We cannot just base treatment to risky therapies based on a limited number of anecdotal reports.


So we do need a systematic approach to evaluating the impact of these and where things seem to be promising, of course, perhaps even launching comparative clinical trials. So I do think this is an interim step to those trials, but one that I think will be very important. And we hope to disseminate this information to our colleagues throughout the country, throughout the world as soon as we feel we have important information to convey.


And I would encourage any oncologist or cancer care provider who is interested to look at the protocol. You can look at the hashtag, which is CCC19, or go to the website or Twitter feed @COVID19nCCC. And you'll see links to the actual website for the protocol and look at the variables that are being collected, and you can indicate your interest in participating or having your institution participate in this. We're talking to other data repository sources, including CancerLinQ with ASCO, to see how we can use this to validate information that's being gathered from other data repositories.


ASCO Daily News: So Dr. Lyman, what are the lessons learned from this pandemic so far that will help inform how oncologists proceed in the weeks and months ahead?


Dr. Gary Lyman: I talk about the post COVID world, which is going to be very different than what we have been used to. We will get by this. Everything tells us that this pandemic will eventually subside, probably at different rates in different regions. There is encouraging information coming out of China, of course. That was the first major country affected by this.


But it's going to be a while. There is not going to be a quick resolution of this anywhere. It's going to take time.


And the more social distancing, protective measures, and resources put to bear on this issue, the more we can, as has been described, flatten the curve and provide a better opportunity for always limited health care resources to not be overwhelmed by this. I'm very concerned that there are regions of the country that are on the brink, if not already being overwhelmed in terms of their health care system.


Certainly, we need more and more federal coordination and resources in terms of coordinating access to hospital beds, ICU beds, ventilators, and, again, protective equipment for those on the front lines and their patients. So hopefully, these lessons, which maybe should have been learned a century ago with the pandemic of 1918-- but memory fades and so forth.


But what we have had have been three pillars that we should have been aware and we can never lose sight of going forward. One is our understanding of biology and virology. We're still early in our understanding of this particular virus. It's a novel coronavirus.


But what we do know already should be conveying to all of us the high contagion, the high transmission of this virus, and the more fatal, serious consequences of acquiring the virus than the historical influenza virus. And this has been part of the problem. The other thing, of course-- we have decades of experience with viral epidemiology, not only with the flu, but with other dangerous viruses on a global basis.


And then one thing that probably did not have enough attention until now is the crystal ball of mathematics, of understanding what exponential growth in the number of cases represents. And without intervention, without protection, without social distancing, that mathematics has predicted and all the trajectories across the globe have demonstrated that this virus progressively, in an exponential fashion, rapidly increase the number of cases and, as a result, the number of deaths that come.


Yes, we can bend that curve down, but it's going to require a concerted effort on all of our parts and adherence to social distancing and personal protective measures. As well as for patients, cancer patients and other of the most vulnerable patients, we need to make sure we're getting the resources where they're needed to care for these patients. It's going to be difficult. It's going to be serious.


And as I've said several times, I can't praise the heroes of this on the front lines, the health care workers, as well as others providing us with food and other resources that help us to still get by as a society while we're fighting this. There are many, many on the front lines here, and we need to do everything we can to both protect them as well as help our patients, our primary charge throughout this whole process.


ASCO Daily News: Well, thank you, Dr. Lyman, for your efforts in this unprecedented health crisis. We will indeed be following up with you and others who are leading this effort to gather crucial data and information to help cancer patients.


Before we go, I'd like to remind our listeners, you can access the registry on social media using #CCC19, and the Twitter handle is @COVID19nCCC. And online, you can access the survey at Thank you, Dr. Lyman. Please do take care.


Dr. Gary Lyman: Thank you, Geraldine. And to everyone, please be safe, stay healthy, and continue to serve your patients. This is our charge. This is our mission, and thank you all for everything you do.


Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.


COI Disclosure: 

Dr. Gary Lyman

Consulting/Advisory Role: G1 Therapeutics, Partners Healthcare, Mylan, Spectrum Pharmaceuticals, invitae, Sandoz-Novartis, Samsung Bioepis, bioTheranostics, Beyond Spring Pharmaceuticals, Daiichi, Sankyo

Research Funding: Amgen