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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.


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

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 the podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts.


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.