Dec 29, 2020
In today's episode, we hear from the internationally renowned medical oncologist and researcher, Dr. Derek Raghavan, president of the Levine Cancer Institute. He reflects on the extraordinary events of 2020 amid the COVID-19 pandemic and discusses the challenges that will confront the oncology community in 2021.
Transcript
ASCO Daily News: Welcome to the ASCO Daily News Podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News.
It's an honor to welcome the internationally renowned medical oncologist and researcher, Dr. Derek Raghavan today. He's president of the Levine Cancer Institute in North Carolina, where his clinical focus is on genitourinary cancer. Dr. Raghavan will reflect on the extraordinary events of a year in which normal life was shut down by a once-in-a-century pandemic. And he discusses the challenges that will confront the oncology community in 2021 as practitioners continue to deal with the impact of COVID-19.
Dr. Raghavan reports no conflicts of interest relating to our topic
today. And full disclosures relating to all episodes of the
ASCO Daily News Podcast are available at
asco.org/podcast.
Dr. Raghavan, welcome back to the ASCO Daily News
Podcast.
Dr. Derek Raghavan: Geraldine, thank you so much.
It's lovely to be talking to you again.
ASCO Daily News: Dr. Raghavan, the impact
of delays in screenings and the reluctance of patients to go into
clinical trials are just a couple of the major issues that will
have to be dealt with in 2021. In your opinion, what are the major
challenges ahead for the oncology community?
Dr. Derek Raghavan: Well, I think we've just come
through a very tough year. Some years ago, Queen Elizabeth II
talked about annus horribilis. And if she thought that year was
bad, this has been a doozy compared to it. So I think what we're
all hoping is 2021 will eventually be a better year. And I think
that's the light at the end of the tunnel for us.
I think the dominant features will still be the coronavirus or
COVID-19. It's not going away in a hurry. And the impact it had in
2020 will still be felt in 2021.
My big concern, and I'm not unique in that concern, is a huge
impact of fear associated with COVID-19 and also the fact that
health care systems have had to deflect patients to keep the
numbers down, to allow us to manage social distancing. The big
impact has been delay of presentation. And I think even in the
latter part of 2020, we've seen patients coming in with more
advanced breast cancers, and colon cancers, and so on.
There's been confusion in the general population about risk benefit
for screening. What is the chance of finding a cancer versus the
risk of getting COVID-19 if you come in? I think it is fair to
say that a little bit--some of the political establishment has
created doubt about the ethics and good intent of the medical
profession. I think that was purely a political ploy. But it has
hurt in terms of the confidence patients have in their physicians.
And there was all the nonsense about physicians making up a story
of COVID-19 so that they could bill for it and things like that. So
that I think has made people more nervous and made them reticent to
come in.
So very similar to 2008, where there was a financial downturn, and
in 2009, 2010, and 2011, it was seen that as people lost--had lost
health insurance and presented late, the stage of presentation went
up. The death rate went up. I think that's got to be something that
we're going to be looking at very carefully. So the whole screening
story is going to be a problem.
I think oftentimes when people lose confidence in biomedicine, the
mixed messages will lead to delayed presentation or discontinuing
treatment early, reluctance to get into clinical trials. So I think
we'll need to address those issues pretty carefully. And I think
some health care systems have suffered bad financial losses. And
that's a mixture of their routine medical practice changing,
numbers of patients staying away, higher costs incurred in trying
to provide safe care, [and] rostering people to be present to take
care of less numbers of patients in order to ensure safety.
I'm quite proud of the health care industry. They're one of the few
groups that really has behaved very responsibly in terms of trying
to keep patients safe and doing the right thing. Many of the
hospital systems have kept people on duty to avoid contributing to
the economic chaos. And that has caused fiscal problems. And while
in and of itself that's something, it goes to the issue of
sustainability, the ability to provide all the resources that have
been provided in the past. So I think these are all going to be
challenges.
ASCO Daily News: So what about the impact
of the pandemic on health care professionals? Do you think some
people will choose to leave oncology?
Dr. Derek Raghavan: I think there's an interesting
and very hard to measure shift. And it isn't just in oncology. I
think it's, in fact, probably less in oncology than elsewhere. And
that is a reduction in morale, where emergency doctors and ICU
doctors put their lives on the line all the time. And then they go
home and they see teenagers clustering without masks, and their
parents looking affectionately at them and endorsing the fact that
they didn't miss their annual celebration for this or that because
it would have been too upsetting. And yet, they've managed to
spread COVID-19 around the community.
And I think that disconnect between the rigor that the physicians
and many nurses have taken in keeping themselves clean and safe and
looking after people, versus a community where large numbers have
not cooperated and have had funny beliefs, has contributed to a
reduction in morale. And I think that might actually show itself
more in 2021 as the intensity of the COVID-19 pandemic
reduces, hopefully, with the introduction of vaccines.
That may be a hard to measure entity. I think we've seen, in many
domains, people leaving health care. So we're going to have
staffing issues unrelated to those people who are on furlough
because of exposure to COVID-19. I think there are absolute numbers
of people that may be losing a little of their enthusiasm, and so
staffing, the ability to provide services will be an issue.
I do think that in the domain of oncology and cancer treatment and
so on, there is generally such a sense of vocation because it is a
tough profession. I think people probably have just accepted that
the patient with cancer and his or her family, on average, are
incredibly thoughtful, careful, committed, and courageous. And so
that's made it easier for people in the cancer treatment and
research space to keep going.
ASCO Daily News: Dr. Raghavan, how will
you deal with the next wave of sick patients at the Levine Cancer
Institute, especially those patients who have delayed treatment and
will present with more advanced disease? How are you handling
this?
Dr. Derek Raghavan: Well, to be honest with you,
we think a surge in patients coming to us is a good thing in the
sense that we've staffed appropriately. I always take the view that
having one too many nurses or one too many physicians is way better
than having one too few. And we've always been very careful to
ensure that we have a holistic approach to our cancer care.
And so I have probably 100 staff who are focused purely on
survivorship and patient symptom control, which I think is perhaps
more than some centers. So we, at the Levine Cancer Institute, have
some flexibility. When I came here coming up to 10 years ago, our
annual new patient accrual was about 6,500 or 7,000. This year,
even with COVID-19, we look like we'll see 18,000 new patients.
And my point is simply to say that we are quite used to the idea
that people have recognized that whatever we're doing is perhaps
right. We had an uptick, which was kind of interesting. We made the
top list in U.S. News and World Report for the first time. And that
suddenly had a whole bunch of patients that had previously not
bothered to come to see us that suddenly showed up. And we've been
able to deal with that quite well.
So the surge in patients I'm less concerned about than the surge in
patients with more advanced disease than we're used to. And so
that's not so much a numbers thing as just being sad that people
have been frightened and have not presented early. The chance of
achieving cure, as you know, Geraldine, is much higher with early
stage disease. From a financial value perspective, managing early
diagnosis cancer is more cost effective because you have a better
chance of cure with less intensive treatment.
So those sorts of things are things we're thinking about. But I
think we're pretty comfortable that our staff is ready to flex up.
I have a training program that has 12 oncology fellows, hematology
and oncology fellows, and multiple other people. I also run a
training program for advanced practice nurses. And we've been, I
think, fairly creative in recognizing the training and commitment
of our advanced practice professionals and leveraging their skill
set so that a lot of the things we've done have been to make the
very sophisticated nurses that we have focusing purely on nursing
duties, and then finding secretarial support or less trained people
to do some of the routine tasks. And that seems to work reasonably
well at our institute.
Certainly I personally have a real interest in the value
proposition. As you know, Geraldine, ASCO has had a great focus on
value and thinking about choosing wisely and so on, and we've built
those principles into the design and execution of the Levine Cancer
Institute. There will be an impact of delayed presentation, I
suspect, because we've gotten better at treatment. Our surgeons are
so adept. We've got better techniques in radiation treatment. We
have a whole range of new targeted therapies.
I often think, when I feel a little discouraged, I think back to
President Jimmy Carter, who at a very advanced age, developed very
advanced melanoma several years ago and is still popping up doing
good work around the community. And that's a fabulous outcome.
So I'm reminded that oncology does a pretty good job with cancer
irrespective of the stage of presentation. Obviously, we like to
see it early because it's better for the patient. They need less
treatment and it's cheaper. But I don't think there's going to be
necessarily a horrendous onslaught of dying patients. But I do
think the level of treatment will be more complex. And I think
we're ready for that.
I think one of the good things that ASCO has done, and I applaud
ASCO, and also the Institute of Medicine some years ago, is to
start making people structure their thinking about wise choices in
treatment, and looking at the costs of treatment, and looking at
the copays that patients will have to expend versus what will they
get back.
And so all of those things, I think, have contributed to bringing
things back to the medium. But having said that, yeah, there'll be
more patients with advanced disease. There'll be a bunch of
patients who show up who have been putting it off and are now
panicking. But I think our profession is committed to doing the
right thing. And so we'll work longer hours and we'll be there for
the community, and we'll treat them as effectively as we can.
ASCO Daily News: Absolutely. Well, let's
focus on clinical trials. You are lead investigator of numerous
clinical trials. How do you think accrual for clinical trials,
which is obviously a very difficult issue at the best of times,
will be affected by the pandemic? And how do you think clinical
trials will be impacted in 2021, and what do you see as the best
path forward for clinical trials?
Dr. Derek Raghavan: In 2021 there will be a
hangover of angst about the risks of coming to medical centers and
the risk of COVID-19 and so on. So I think there will be some
potential diminution in people showing up for clinical trials. And
the issue of politicians who have made a big thing of how the
medical profession is no longer trustworthy will hurt there because
trust is very big part of a patient feeling comfortable to go into
clinical trials, and particularly so in the minority
communities.
In the Black American community, there is still a hangover, 50
years later or more, from the Tuskegee experience. We have now
checks and balances in place that generally stop that, but I think
when you have politicians saying that doctors are bad people, there
will be the less educated community that believe them and get
frightened. So I think that will hurt trial accrual somewhat.
Having said that, I would also add that we've contributed to reduce
trial accrual. Most of the big and responsible cancer centers cut
back their accrual to phase I trials, and maybe some phase II
trials, at the height of the COVID-19 epidemic, or the early
height. And the thinking there was one, we didn't know how bad it
would be, and how quickly people could catch COVID-19 from
medical professionals. We didn't know whether drugs that would
cause suppressed immunity would make people even more vulnerable.
And so many units reduced the population of patients coming through
clinical trials.
At the Levine Cancer Institute, we did that, particularly in the
space of phase I trials. We kept our CAR-T chimeric antigen
receptor therapy program going because we already knew that we were
seeing amazing responses in myeloma and lymphoma particularly
(NCT04133636). And so we could
justify doing it in view of the lethality of the conditions that
were being treated.
But we still shut down a lot of our work. And what we did was we
actually flipped very quickly to testing novel therapeutic
compounds against COVID-19. And so oddly enough, we did one study
with--I think it was, if I recall, GlaxoSmithKline--where we opened
a trial, got all the paperwork done, had our independent IRB. We
had an external IRB review it. And we entered our first patient
within about a month of presentation of the draft protocol. And it
turned out to be the first patient entered worldwide. So we flipped
a very efficient cancer trials mechanism into a COVID-19 virus
mechanism.
At the Atrium Health Group, my colleague Dr. Christine Turley, who
is a pediatrician, not an oncologist, has opened a vast array of
vaccine studies. And so we've been active participants there, and
that continues today. So I think the trials mechanisms have been
leveraged in as sensible a way as possible.
Now moving into 2021, I would anticipate that we'll be recruiting
patients pretty rapidly back to trials from the backlog of people
who've presented with more advanced disease. At Levine, we enter
each year about 1,000 patients into therapy trials and about
another 500 or 1,000 into translational studies. And so we had a
bit of a diminution in volume, but it's already picked up pretty
dramatically.
ASCO Daily News: Telehealth has been
heralded as a great success during the pandemic, and many see this
as something that will outlive the pandemic. Do you share this
view?
Dr. Derek Raghavan: Yeah, I do. I think it's been
very successful and very helpful. I think it has provided the
basics of medical contact, which are crucially important to
patients with cancer and many other diseases. And I would say that
our physicians and nurses have become much more adept at
communicating with patients professionally using the various
virtual platforms.
The tricky part is that it does select somewhat against the
underprivileged because while the wealthy insured person might have
very sophisticated electronic equipment and be able very easily to
enter into a video consultation, many of the people in the
underserved communities actually don't have that kind of hardware
or software or anything else. And so they will be sometimes hard to
get to, or at best, they'll get a phone consultation, which
precludes the physician from actually being able to at least look
at them and get a sense of if they look well or unwell.
Just yesterday I was in the clinic at our local VA hospital. That's
where I do most of my clinical work. And I was thinking about the
difference between the virtual consults I've been doing and the
fact that as a patient walks through the door, I already have a
snap judgment. This patient--and I treat mostly prostate cancer--so
this patient is obviously uncomfortable and unwell and I need to be
worried, versus there's a spring in his step and a smile on his
face, and his color is good, and he's probably fine.
You lose that somewhat in virtual consultation. Some years ago, I
wrote a kind of slightly facetious editorial for the journal
HemOnc Today, which I entitled "Having Your Rectal Examination in
the Grocery Store in the Produce Section." And the point I was
making was that so many medical entities are starting to provide
some level of quasi-medical care to make money in their operations
under the rubric of making it accessible.
And the point I was making was there's very little quality control
in terms of long-term outcomes in that situation. My concern, where
you have virtual care in the hospital regulated environment, is
there will be things that we don't yet know that you miss. So for
instance, I'm not a breast cancer specialist, but from my general
medical days, oncology days, I remember that one of the crucial
things in a follow-up examination for a patient with breast cancer
was to examine the patient carefully and to examine the
contralateral breast, or the ipsilateral breast if there had been
breast-conserving surgery.
The argument that the technocrat's will give would be, oh, well you
can always get a mammogram done, and that's true. But the reality
is, every experienced practicing oncologist knows that a test in
isolation is no substitute for a test plus a good history taking
and physical exam. And while there are many people that would like
to dumb down the importance of good clinical medicine, my belief is
still the sine qua non of safe care.
And so I embrace virtual consultation. I think there are many
domains where it's very helpful, particularly survivorship
activities and psychological counseling activities. I think you can
do some really good work with patients who don't have to have the
vulnerability of leaving home and all the nonsense of getting a
babysitter and getting transport and so on. It will always be here
from now on.
But we need to develop caveats of where is it safe, where is it
not, where do mistakes get made, what is the impact on the
doctor-patient relationship. And so I think it's a great innovation
and it will not go away, and that's a good thing. But we're now
going to have to fine tune it so that it doesn't discriminate
against the underserved and so that it is able to serve patients
fully.
ASCO Daily News: Well, you raise great
points about equity of care. So what will 2021 mean for equity of
care?
Dr. Derek Raghavan: Well, I think a very important
point is that Dr. Lori Pierce, a famous radiation oncologist from
Michigan, is now the president of ASCO. And she has made equity of
care her signature. She's not the first person to do it, but it
hasn't been there for a while. And in fact, previously the focus
was more on identifying disparities of care and thinking about how
to address them, whereas now we're talking about equity, which
means equal outcomes.
I was very proud of my colleagues Faye Hugh and Nilanjan Ghosh, who
presented some data from the Levine at ASH, the American Society of
Hematology, last year, where they looked at our experience with
diffuse large B-cell lymphoma in wealthy whites and poor
underserved mostly Blacks and other populations. And we were able
to demonstrate identical outcomes that were as good as any in the
country for wealthy whites.
So we believe that we figured out how to address those disparities
of care so we're producing equity. The ability to demonstrate that
sets a target for everyone. If we can do it, then any major center
can do it, and it's a question of figuring out what is the secret
sauce, and how do you do that.
So I think 2021, with Lori Pierce's stimulus and Cliff Huddis as
CEO of ASCO, who's always had that interest at the administrative
helm, I think ASCO is going to make some good progress there.
There's a lot more being written in the journals. The bar is being
raised so that people are now looking for better outcomes rather
than just saying, let's have meetings and think about it.
I can recall--I'm going to guess maybe 10, 12 years ago--I had the
chance to talk to the President's Cancer Panel. And my one-line
summary of everything I said was avoid analysis paralysis. Don't
keep having meetings and thinking of doing a wonderful thing. Get
programs going and fine tune them as you go.
When I chaired the ASCO Disparities of Care committee many years
ago with Dr. Otis Brawley, we did something that I think was
important. And with support from the Komen Foundation, we created a
program for recruiting people of color into oncology, and then
keeping them in underserved communities by helping them pay off
their college loans. That was a tremendously important step that
ASCO took, not so much because of the individuals that were
trained, but because of the paradigm that it set that we should
take that responsibility as an organization and move things
forward.
ASCO Daily News: Absolutely. Let's focus
on staff support for a moment. So there are high levels of burnout
and moral distress in the best of times in oncology. But the
pandemic has made things much worse. Is this something that
continues to be on your mind, and how will you address this in
2021?
Dr. Derek Raghavan: Yeah. I think you raise an
important problem. You know, I think the disappointment that some
physicians and nurses have felt at the lack of support of the
community, we haven't yet really felt the true impact of that, the
feeling the doctors and nurses and allied health professionals are
waging a campaign.
You might recall, Geraldine, that in one of the states, there was a
very dramatic moment on television where we saw a series of five,
10 ICU nurses in scrubs standing with their arms folded with a sign
that said something like Masks Matter and a bunch of yahoos
screaming at them, screaming abuse at them, saying they were making
it up.
Now that sort of thing is not easily erased from one's mind. And so
I think with respect to burnout and disappointment, that that's
there. On the other hand, I've felt pretty strongly--and it's an
odd thing because I'm actually the guest lecturer at the College of
Nursing's graduation here in Charlotte--and my theme is, in part,
that what COVID-19 has done is it's brought out the best in
medicine and nursing. It's refocused us on people who need us to be
at the top of our game.
And what it's done is you can't help but watch any television
broadcast where you see an ED or an ICU nurse talking about the
experience of helping a patient through the final phase of life,
where the best they can offer is a telephone talk to a member of
the family. Now you know, sadly, my father-in-law died of COVID-19
down in Florida this year. And my wife was unable to get to him
physically, and actually wasn't even able to get him on the phone
because of the center he was in. That was pretty tough for her. And
the nursing staff who looked after him and communicated post hoc
were very, very good.
So this has focused medicine and nursing I'm doing the right thing.
I think over the years we've become a little bit sloppy. We've
gotten focused on publication and self-gratification and all sorts
of things that aren't the essence of complete medicine. And
COVID-19 has made us force our thinking back into doing the
right thing. And I think that'll be good for medicine and nursing
for a long time.
So in 2021, as the pressure eases, as we have less volume overload,
I think you'll find that we'll come out of that a little better. In
the oncology space, it is my firm belief that we super select. The
people who go into oncology, practice in oncology nursing, are a
very special group. And I think they're selected because they're
patients, and the patients' families are a very special group. It's
a microcosm that's a really important one, and interestingly, one
that has not changed in the 40-ish years that I've been in medical
practice.
So I think 2021 will be OK. There's no question that burnout is an
issue and always has been in oncology, and you have to plan for
that. So in my center, you may recall that we were certified by the
Planetree International, Inc., which is all about quality of
patient care and patient-centricity. Part of that philosophy has to
do with ensuring that the doctors and nurses are looked after
proactively.
And so the Levine Institute has a bunch of sessions that relate to
burnout at any time. We've ramped those up a little bit. So it's an
ongoing thing. And I think the very best cancer centers have that
built into their culture. I know most of the key cancer center
directors around the country, and when I talk about what we're
doing, they don't go, oh, wow. They say, yeah, we're doing the same
type of thing.
And so I think we heal ourselves continually as part of
understanding that there is going to be burnout and trying to
minimize it. It is a tough profession even without COVID-19.
COVID-19 just makes it a little tougher. And the interesting thing
is that at one time, the cancer doctors are the sort of high end of
social contact and social conscience. Now, with all the people
addressing COVID-19, and in the hospital, patients who are sick
with COVID-19, that discriminant gone away a little bit. We, as
cancer doctors, are looking at our colleagues saying, you guys are
doing pretty much what we do every day of the week. And we're proud
of you for lifting your game and dealing with it.
ASCO Daily News: Well, it is always a
great pleasure to hear your insights, and I really appreciate your
time today, Dr. Raghavan. And I wish you all the best in 2021.
Dr. Derek Raghavan: Thank you, Geraldine. Always
enjoy talking to you. Thanks very much.
ASCO Daily News: And thank you to our
listeners for joining us today. If you're enjoying the content on
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Disclosures:
Consulting or Advisory Role: Gerson Lehrman Group, Caris Life Sciences
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.