Managing Cancer Care Amid COVID-19 Pandemic

Aislinn Antrim: Hi, this is a Aislinn Antrim from Pharmacy Times. Before we get started today, one of our top stories is about a new FDA-approved saliva test for COVID-19. Experts at Rutgers University created the test, and you can read more about it on Oharmacy Times. Today, I'm speaking with David Hughes, clinical pharmacy specialist in hematology and oncology at Boston Medical Center, and Radhika Jhaveri, a clinical manager there who oversees the infusion-based chemotherapy. They're going to be speaking with us regarding how COVID-19 has affected cancer care. Okay, can both of you just give us an overview of some of your big concerns about how COVID-19 has affected your patients?

David Hughes, PharmD, BCOP: Yeah, sure. So, you know, I think one of the biggest concerns is being in a population that's essentially immunocompromised, the concerns of frequent chemotherapy visits in clinic, ongoing laboratory draws. I mean, within oncology, a lot of our patients always are going to need recurrent labs, they're going to need to come in for provider assessments, they're going to be getting chemotherapy. And these patients are coming in more frequently than I think, you know, maybe some other clinics operate. So I think one of the biggest challenges here is constantly coming in and risking the sense of exposure to patients that are otherwise at an immunocompromised state.

Radhika Jhaveri, PharmD: Yeah, I think that, similar to what David said, when the pandemic first started our hospital instituted a lot of measures right away, in terms of screening patients prior to coming into the clinic with a phone screen as well as screening them again when they physically arrived at the hospital. And I think the institution has really done a great job there. And, you know, we've also tried our best to be able to ensure patients that we're taking all of the precautions, that they are still safe to come into the hospital. Just like David mentioned, these are patients that do need to be seen a little bit more frequently than some other ambulatory patients, so Boston Medical Center has done a great job ensuring to them that they are still safe to come in and we've put all safety measures into place.

Aislinn Antrim: Excellent. Of course, all cancer patients are immunosuppressed to some level. Are there any specific conditions you’re particularly concerned about, such as lung cancer

patients or anything else?

David Hughes, PharmD, BCOP: We treat all patients to a level of immuno-compromised state. You know, obviously there are certain disease states where patients, depending on what treatment they're on, maybe we have like lower risk factors. You know, there's a lot of theoretical concerns that some of the monoclonal antibodies or b-cell depleting therapies may pose higher risks for patients, it may put them at higher risk of developing COVID. But, you know, across the board, regardless of cancer, we've kind of established that the majority of our patients who are at some form of immunocompromised state are at a higher risk than the general population. And overall, you know, we are at Boston Medical Center, we have the highest amount of caution for all of our patients across the board.

Radhika Jhaveri, PharmD: Yeah, so one of the things we've done is actually—so, we have a stem cell transplant program, an autologous stem cell transplant program, and those patients often are at a really high risk post-transplant especially. So right now, actually, our transplant program is on hold and we've actually delayed patients’ transplants to basically avoid them

from reaching that severe immunocompromised state. We did do one or two transplants that were sort of critically necessary to happen on time, and so once again we put all precautions into place. But that would be one area, maybe, of our program that was definitely affected, where we knew these patients would be extremely high-risk and if they can be safely delayed then that's what should be done. And that's what's done for all of those patients. So these are typically patients that have amyloidosis and multiple myeloma.

Aislinn Antrim: Okay, do you have recommendations for patients who have completed therapy rather than are on active therapy? What should they be doing?

Radhika Jhaveri, PharmD: I think they should be taking the same precautions that the general public is taking. Generally, patients who have completed therapy, if they are not still active, you know, they're technically not actively immunocompromised, and if their cancer is either in remission or cured then their risk of contracting COVID-19 is similar to the general population. So they should still be taking all of those same safety measures that the general population is

being asked to do.

David Hughes, PharmD, BCOP: You know, one of the great things going forward is that a lot of these patients, as Radhika mentioned, like either completed therapy, are at a curative state where, you know, they're generally monitored either like every six months or annually after

that to assess like recurrence, and the great part is with technology now a lot of these visits are able to be done remotely to you know prioritize. Say, is it really a benefit for this patient to come in for their annual checkup or is it okay that we delay or, even better, use like a telemedicine visit and then assess over the phone via videoconferencing. And then, you know, see at that point does this patient actually need to be seen? So those are some of the other additional recommendations that we're doing here at BMC to really help optimize care.

Aislinn Antrim: Wonderful. You mentioned that there were some necessary stem cell transplants. How are you making those clinical decisions for those patients that needed

to continue for any sort of treatment, whether to wait or continue?

Radhika Jhaveri, PharmD: I mean, most of the providers are obviously going to drive that decision, so that would be the patient's oncologists or the nurse practitioner in conjunction with the oncologist. You know, I think it's really a risk versus benefit, you know. So if you hold therapy you're at risk of making the cancer worse or progress or symptomatic, and if you

didn't hold therapy possibly you're at risk for now having received chemo and being immunocompromised. So I think it's a very difficult tricky situation, so I think the providers are sort of just assessing it case by case. But I would say most of our patients who are actively receiving chemotherapies for some of, you know, sort of our standards—we see a lot of breast

cancer, colon cancer, lung cancer—those patients generally have been able to come in and get their therapies as long as they get screened and do not you know exhibit any symptoms upfront.

Aislinn Antrim: Okay. You mentioned screenings—what other safety measures are in place for those patients?

David Hughes, PharmD, BCOP: Yeah, so I think one of the biggest things is screening regardless

of who comes into our building. You know, we definitely have taken good measures—that’s screening all patients, we've been restricting a lot of the visitors and limiting the amount of people that are actually in the infusion clinic. I think one of the other important things to note

for safety measures that we've been doing is, Boston Medical Center, as you know, has a specialty pharmacy. What we've been doing is switching a lot of our patients to oral equivalent

therapies for patients that can use an oral therapy for that and do self-monitoring at home.

A couple examples that we have is, you know, patients that get weekly bortezomib-based theraoy for myeloma, you know, there is an oral proteasome inhibitor out—ixazomib. You know, obviously it hasn't been as well studied as bortezomib, but it does offer another alternative for patients to be on therapy without coming in on a weekly basis. I know another area is chronic ITP, which patients were coming weekly for their romiplostim injections, and these patients might be transitioned to an oral TPL agonist like eltrombopag or avatromopag. And, you know, patients that get gluorouracil infusions—these are patients that come in every two week for hookups to get home infusion pumps, and what we're doing is seeing an equivalent in oral capecitabine and transitioning patients to oral therapy that way. So, you know, a lot of measures are being taken for these patients, you know, and I think one of the biggest things is switching them to almost a remote self-monitoring program and really

reducing the amount of clinic visits we're seeing.

Aislinn Antrim: Certainly. Are you seeing any shortages? PPEs are having a huge issue but any drug shortages?

Radhika Jhaveri, PharmD: So, I mean, I think like most hospitals across the country everybody was faced with PPE shortages, but, you know, we've been really lucky at BMC. Obviously, we've

received a lot of help from the state of Massachusetts, there's been a lot of donations being made, so we have not felt that significant impact of PPE shortages. Everyone is being protected as well as they can be, both staff as well as patients, so I’m really grateful for all of those who donate, but especially the state also for stepping up and helping us out. In terms of drug

shortages, I haven't seen any significant impacts in oncology. Obviously, we know there are a lot of shortages surrounding sedatives and paralytics, pain medications, and we haven't seen anything in our field in oncology.

Aislinn Antrim: Good. We've discussed a lot of preventive measures, but what would the clinical plan—and obviously it would be different for each patient—but are there plans for patients if they are also diagnosed with COVID-19?

David Hughes, PharmD, BCOP: You know, I think that's a large issue right now, and definitely

something that shouldn't be taken lightly. I mean, obviously the primary concern is to treat them for COVID, and then once they've been fully treated the question is going to become, when do we reinitiate chemotherapy? And I think a lot of that weight comes onto the oncologist to determine, is this patient curative intent? Does this patient have a curative cancer that is not metastatic yet, versus is it a metastatic patient? And, you know, a lot of those decisions are very difficult to make in this time, but ultimately we know that chemotherapy does not come without risks. A lot of the evidence for COVID, you know, suggests that we're shedding the virus 30 days after exposure and these symptoms may hang around a lot and so I don't think patients necessarily are always out of the clear as soon as they may be discharged from the hospital. But they definitely need to have a risk-benefit discussion on whether or not, you know, if they're a curative patient, you know, that their oncologist and the team is going to

want to treat them as quickly as possible and not really delay their care.

Radhika Jhaveri, PharmD: In terms of the actual COVID-19 we're following our hospital infectious disease protocol, and then it's really going to be a discussion, like David, said

after treatment is done when do you resume chemotherapy? And I think that's going to be a difficult conversation to have. I don't think we really know answer that question yet.

Aislinn Antrim: Certainly. Is there anything you wanted to add?

David Hughes, PharmD, BCOP: You know, I think there's a couple pieces. One, you know, one of the downsides to obviously COVID right now, aside from the cancer care is our clinical trials pretty much stopped enrolling. I know a lot of the focus right now has been towards coronavirus-focused initiatives, so a lot of ongoing clinical trials for different types of tumors and things have really come to a halt, which puts a significant challenge for patients that may be candidates for clinical trials. We're working currently at Boston Medical Center to work with actually an anti-cancer therapy in looking at XPO inhibition and how that will relate to coronavirus, so that's something we're looking at for our patients and utilizing the knowledge of oncology pharmacist and what we can bring and what we can bring forward right now is the knowledge we've used with inhibitors and other disease states and hematology. I think one other thing that would be important is looking at the involvement from pharma in like what role they have for our patient populations. Obviously, you know, the drugs used in oncology always come with great cost. I think one of the things that a lot of pharmaceutical companies

are doing, especially for patients that are on patient assistance programs, are providing patient drugs. You know, patients that are already on these programs are actually supplying them to

in three-month supplies, our specialty pharmacy is continuing to provide two- and three-month supplies to patients for these specialty products, ultimately to avoid them coming into clinic, but at the same time making sure and they feel comfortable having a fair amount of medication on hand so that their health is not impeded from this virus.

Radhika Jhaveri, PharmD: Yeah, I mean, I think you know it's definitely a difficult time, it’s something that no one has dealt with before, and so it really took a lot of planning in the initial stages when all of this started happening. So I think it was a great group effort between our

operations and our clinical teams to really figure out how are we going to keep everything safe for both our patients as well as our staff. And so, you know, Boston Medical has been

really great. We get daily updates from the hospital operations team about sort of what's

happening all across the institution. You know, we're working very closely with all of our teams here in our infusion clinic. One thing we are getting a lot of requests for from both patients and

providers is maybe pursuing home infusions. You know, so obviously, ideally we want patients to come into our infusion clinic to get their infusions, but during this time is it possible to tap into maybe home infusion companies to be able to do a couple of their infusions at home for the upcoming, you know, months. So that's something we're trying to look into, if that's a possibility. So all the new sort of avenues for us to pursue and every day it's a new challenge, but I have to say that it's been really great sort of collaborating with everybody and the institution has really been very helpful to both patients and staff, keeping us updated with everything that's going on.

Aislinn Antrim: That's wonderful. Thank you both for taking the time. Now, let’s hear from some of our other MJH Life Sciences brands on their latest headlines.