Oncology in the Time of COVID-19

April 10, 2020

We are facing difficult decisions and choices as we await the tsunami of COVID-19 cases. Despite the experience of our Chinese colleagues and their government through January, we did not anticipate the surge of infection and institute appropriate contagion policies at entry points and ramp up our medical supplies and capacity. As shown by recent graphs, we are about to hit the exponential phase of the outbreak, on track with China, Italy, and the rest of Europe. Britain may prove the unfortunate exception as they eschewed social distancing for the concept of “herd immunity” until just recently. The British National Health Service has less capacity than other systems; therefore, it is less able to react to this policy. Conversely, the countries that have “flattened the curve,” including Taiwan, South Korea, and Singapore, were the ones who developed effective strategies during the prior severe acute respiratory syndrome (SARS) epidemic. They instituted aggressive screening at entry points and quarantining of suspected infected individuals.

As I walk through the streets of Manhattan today, I am reminded of walking through a ghostly Times Square on 9/11. All aspects of communal life have ground to a halt for the foreseeable future. Cultural institutions have shut down. We are sheltering in place. We, at Rutgers, have delayed elective surgeries, exchanged in-person routine follow-ups for phone or telemedicine interactions, and reduced staff gatherings or conferences in favor of video conferencing. Walking through the quiet hospital today seems like a slow weekend day, yet we know that soon we will be overwhelmed. We must learn the appropriate lessons for the next inevitable pandemic.

As Governor Andrew Cuomo of New York stated last week, if you do the math, you will break out in a sweat, hives, and palpitations. Nine million people live in New York City (NYC). If one-third of the population are infected, there will be 3 million cases, and if 10% require hospital-level care, 300,000 hospital beds will be needed. If 1% require intensive care unit (ICU)-level care and ventilators, that means 30,000 intensive beds will be needed. NYC has about 27,000 hospital beds and 5000 ICU beds, not to mention an inadequate number of medical professionals, including respiratory care therapists. I spent 30 years training and attending at Bellevue Hospital and New York University, and was on the frontline of the AIDS epidemic. I know there is no excess capacity. There is no excess capacity in NYC hospitals and our facilities are on the edge of being overwhelmed.

The federal government has failed to prepare in advance for this crisis, lead during the crisis, or plan for its aftermath. Blame has been shifted to prior administrations and current efforts have been shifted to state and city governments. Federal responsibility has been absent even though we are dealing with an infectious agent that does not recognize geographic or political boundaries, race, ethnicity, or political affiliation. We need a surge capacity of 5 to 10 times the current capacity. Healthcare workers are on the frontline, yet we do not have the basic equipment to fight this war. The federal government should nationalize medical supply production and acquisition to ensure supply and prevent crippling price gouging. A coordinated federal response is necessary to prevent our tightly stretched medical network from breaking.

What are we facing and what are we doing:

1.     Lack of testing is a critical problem. We are quarantining our staff who have had fevers despite minimal or no exposure. We need tremendous access to nucleic acid testing to screen those who are symptomatic and those who are asymptomatic, yet are potentially exposed. We are forcing desperately needed medical personnel to shelter in place since we cannot tell who is infected with COVID-19. We also need increased access to enzyme-linked immunosorbent assay testing for immunoglobulin (Ig) M and IgG antibodies to determine who is immune and safe from further infection. This problem has yet to be discussed in detail.

2.     No meetings except online. I still miss seeing my colleagues, but safety first.

3.     Lack of personal protective equipment. N95 respirator masks and other protective gear are already being rationed and the peak is coming in the next 2 to 3 weeks when demand will explode. Our first responders and healthcare providers are incredibly vulnerable to infection. In China, exposed medical care providers were housed in special dormitories and hospitals to prevent potentially spreading the infection outside, yet this has not been discussed in the United States.

4.     Cancelling all nonessential patient interactions and scheduling telemedicine or phone encounters.

5.     Rotating our research staff, with half on site and half working at home on alternate days. This buddy system has worked well and now extends to our clinical nursing staff.

6.     Continuing routine cancer care and treatment as an “essential service.” We will continue to do this as long as we have the necessary personnel and resources and as long as it is deemed safe to bring in these vulnerable patients.

7.     Continuing our therapeutic clinical trials also as “essential research.” Accrual to nontherapeutic trials has been suspended. The FDA and National Cancer Institute have issued guidelines on clinical trial patient care at local offices and laboratories with remote interactions. Oral investigational agents can be shipped to patients. We will continue this approach as long as we have the personnel and resources necessary.

8.     Beginning to triage. Colleagues in Washington State are already making contingency plans to cease treating patients with cancer. We are not thinking in that direction yet but are certain to consider prioritizing potentially curative treatments over “palliative” treatments. Difficult choices are ahead.

The next few weeks will be replete with daily challenges and crises. I encourage you to read the Handbook of COVID-19 Prevention and Treatment which details management policies developed through difficult experience by our Chinese colleagues. The Jack Ma Foundation and Alibaba Foundation have enabled us to download it at: https://covid-19.alibabacloud.com.

We will continue, as always, to do our duty to render the absolute best care to our patients and remain healthy ourselves. I extend my heartfelt prayers for your health and safety in the coming days.

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