Dr. Halmos on Adapting Practice in Response to the COVID-19 Crisis

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Partner | Cancer Centers | <b>Montefiore Einstein Cancer Center</b>

Balazs Halmos, MD, MS, provides insight into how his institution continues to adapt in response to the COVID-19 crisis.

Balazs Halmos, MD, MS, director of Thoracic Oncology and Clinical Cancer Genomics at the Montefiore Albert Einstein Cancer Center, provides insight into how his institution continues to adapt in response to the COVID-19 crisis.

COVID-19 started an epidemic of significant proportions in China, and the virus has since spread across the globe, says Halmos. Certain parts of the United States, such as New York City, have been hit especially hard by the virus, with over 117,000 cases. The pandemic forced providers to urgently reconsider how to care not only for patients with the virus, but for patients with cancer who still require treatment for their disease, adds Halmos.

The Montefiore healthcare system took action early on, says Halmos, in that they decided to move all patients with cancer into 1 freestanding facility. Efforts are being made to provide safe access to the facility through the use of screening at entry points, providing masks to all patients who enter the clinic, and ensuring that all providers have the appropriate personal protective equipment when providing care, explains Halmos. Through these efforts, it is hoped that the potential for infection will be reduced.

One of the challenges faced by providers who are working in the lung cancer space specifically is differentiating between symptoms that may be associated with treatment versus those that may be a result of the infection with the virus, says Halmos. Pulmonary complications can result from treatment with many available agents in lung cancer. For example, patients receiving checkpoint inhibitors may experience pneumonitis, and targeted agents could result in lung complications. Many of these symptoms could mimic the changes seen with COVID-19 infection, says Halmos.

This challenge can be greatly diminished, however, with the use of rapid COVID-19 testing, adds Halmos. With in-house testing, providers in New York are making great strides. The test is easy for a molecular lab to run and medical students have been recruited by molecular pathologists to assist in running such tests. As such, results for these tests can be turned around in a matter of a couple of hours versus 3-5 days, says Halmos.

In an effort to prevent patients from infection, many providers have shifted to the use of telemedicine, where appropriate. For example, if a patient just had a CT scan and their scan results were negative, those results can be discussed over the phone rather than in person, says Halmos. Additionally, visits can be delayed for patients who are supposed to come in every 6 months as follow-up. However, some patients will still need to come in to receive appropriate treatment; that’s why all the preventive measures are in place to protect them from infection.

Treatment modifications also need to be made for some patients, posing yet another challenge, says Halmos. If a patient has a life-threatening infection in the middle of aggressive chemotherapy, when their immune system is suppressed, their outcome might be a lot worse that it might have been otherwise. As such, providers may opt to diminish the aggressiveness of chemotherapy, delay some treatments, limit the number of required visits, choose oral alternatives rather than intravenous agents, and potentially offer deferral of treatment. Additionally, checkpoint inhibitors could potentially be administered on a lighter schedule, says Halmos, such as every 4 weeks rather than every 2 weeks.

Through it all, Twitter has become a platform for patients and providers alike from all around the world to share information and personal experiences with the virus. Through this platform, providers in the United States are learning from the experiences of who are practicing in China or Italy, and they are applying that knowledge to treatment decisions faced in the clinic, says Halmos.

One of the biggest challenges faced right now is determining how to appropriately manage patients, says Halmos. Providers are used to knowing that there are guidelines, recommendations, and rules in place for treatment, that there is a standard of care to follow for certain situations; however, in light of the pandemic, many are finding themselves having to compromise on certain aspects of care, says Halmos.

Many of times, the standard of care cannot be provided. Then it becomes a matter of finding a second-best alternative solution that could still help patients in the meantime, adds Halmos. For example, if surgery is not being performed and a patient needs surgery, is there an alternative approach that can be taken to defer surgery for a little bit so that reasonable safety can be offered? Many times, there is no certain “right” answer, says Halmos, and providers are forced to come up with makeshift decisions based on the tools and information available.

Another component is the emotional element associated with the pandemic, says Halmos. Of course, providers are very anxious during these times, but so are the patients. Patients with a life-threatening illness might be admitted to the hospital where they cannot be joined by their family members. Key decisions may need to be reached and they do not have that support system with them to make those decisions. As such, providers need to go the extra mile to still provide the care, compassion, and attention that these patients need during such a traumatic time, stresses Halmos.

In an effort to quell the pandemic, many investigators worldwide have been channeling their efforts into conducting clinical trials. Some of these trials are examining antiviral agents, while others are evaluating novel agents that block the cytokine storm that is associated with the virus, says Halmos. Another interesting effort is taking the serum from patients who recovered from infection with COVID-19 and treating critically ill patients with that serum. Vaccine studies are in the development, as well. Although the efforts and the speed with which they were initiated are very impressive, nothing groundbreaking is going to happen within the next few days or even months, says Halmos; that’s why it’s important to utilize the resources available to keep patients as safe and healthy as possible.

One of the biggest weapons in the arsenal against the virus is flexibility, says Halmos. Providers and healthcare systems must rapidly adapt to the changes that come with the pandemic. This is a time to come together, says Halmos. Through collaboration and shared experiences, the world will pull through this challenging time, concludes Halmos.

Please visit www.OncLive.com to watch the entitreity of the MJH Life Sciences News Network, which provides the latest news across a variety of healthcare specialties, and a number of interviews with experts in the medical field, many of which are focused on the ongoing COVID-19 pandemic.