AI transcript
0:00:04 – Hi and welcome to the A16Z podcast, I’m Hannah.
0:00:07 We’re talking today about what is happening to oncology
0:00:09 and to patients going through cancer treatment
0:00:11 during the outbreak of coronavirus.
0:00:12 How treatment is affected,
0:00:15 what kind of clinical decisions oncologists
0:00:17 are having to make, what kind of new tools
0:00:20 and what happens to oncology as a whole
0:00:23 when it’s forced in this moment to go so virtual.
0:00:25 Joining myself and Venita Agarwalha,
0:00:28 physician and general partner at A16Z
0:00:30 are Dr. Bobby Green, community oncologist
0:00:33 and chief medical officer at Flatiron Health,
0:00:34 who is the first boy seal here,
0:00:38 and Dr. Sumit Shah, oncologist and head of digital health
0:00:40 at the Stanford Cancer Center.
0:00:43 We’re here today because coronavirus is now disrupting
0:00:46 the entire healthcare system,
0:00:48 not just because of the burden of dealing
0:00:49 with the actual disease itself,
0:00:50 but because of everything else
0:00:52 that’s had to grind to a halt.
0:00:56 One of those areas where we really worry about things
0:00:57 coming to a total stop like that
0:00:59 is of course cancer treatment,
0:01:01 which can often feel like a race against the clock,
0:01:04 even under the best conditions.
0:01:07 So can we just start by talking about the biggest issues
0:01:09 that your cancer patients are facing right now?
0:01:12 – I’ve been sort of, I guess, surprised
0:01:15 how much more resilience I’ve actually seen
0:01:17 among a lot of my patients.
0:01:19 And maybe it’s just because they’ve lived
0:01:20 through so much uncertainty
0:01:23 and gone through so much as part of their diagnoses
0:01:26 that this is just one more thing.
0:01:29 But I do think people have been remarkably resilient
0:01:33 and in fact, in some ways a lot more so
0:01:35 and maybe more laid back about this
0:01:38 than some of my healthy friends and colleagues
0:01:41 who haven’t had to deal with any health crisis.
0:01:42 There’s been a little bit of confusion
0:01:45 about what does it mean for my treatments
0:01:46 and uncertainty about timing,
0:01:47 ’cause I think none of us really know
0:01:48 how long is this gonna last
0:01:51 and how long is the world gonna look like this.
0:01:54 And then also the other thing I’ve sort of seen,
0:01:57 and fortunately I haven’t had any patients
0:01:59 that I know of who have been laid off.
0:02:03 But I think uncertainty about jobs and people,
0:02:04 most people have their health insurance,
0:02:07 as we all know, if they’re not on Medicare
0:02:09 through their place of employment.
0:02:11 And that’s a concern as well.
0:02:13 – Yeah, I totally echo what you said about resilience, Bobby.
0:02:16 I had a patient last week who told me,
0:02:19 who told our team that they can empathize
0:02:21 with what everybody’s going through
0:02:23 because it’s exactly what they’ve felt like
0:02:24 every time they had chemotherapy,
0:02:27 that they’re suddenly susceptible to infection
0:02:29 and that they have to be careful.
0:02:31 And that was like their dominant reflection
0:02:33 is that I understand why everyone is afraid.
0:02:36 And I’ve felt that fear myself,
0:02:41 which was an incredibly sort of empathic
0:02:43 and resilient thing for somebody to say
0:02:45 you could have been worried entirely about their own care.
0:02:47 – It feels like from the outside,
0:02:49 you’d imagine that would almost double
0:02:51 that you’d get sort of extra doses of that fear
0:02:54 instead of almost being like inoculated against it
0:02:55 because you’ve gotten so used to it.
0:02:57 That’s really inspiring.
0:02:58 – Yeah, I will agree with you guys
0:03:00 that I think most of our patients
0:03:01 have been incredibly resilient
0:03:03 and understanding of the current time.
0:03:05 But I’ve also had a fair number of patients tell me,
0:03:08 Dr. Shaw, my cancer can’t shelter in place.
0:03:09 What do I do right now?
0:03:12 Which is a very poignant point as well.
0:03:14 So I think a lot of the patients are wondering
0:03:16 about the timing of chemotherapy.
0:03:17 Should I initiate chemotherapy?
0:03:19 Should I delay chemotherapy?
0:03:21 What are the risks of doing so?
0:03:23 Am I going to put my body at higher jeopardy
0:03:26 for becoming immunocompromised?
0:03:28 Or am I going to leave my body at higher risk
0:03:30 for this coming back in the future?
0:03:33 So these are very difficult decisions to kind of make.
0:03:34 And we don’t have a whole lot of data
0:03:37 to help us support that decision-making capacity.
0:03:39 So a lot of this is done on a case-by-case basis.
0:03:44 – I think a lot of providers are discussing the Lancet paper
0:03:49 about a relatively small cohort of 18 cancer patients
0:03:52 who got infected with coronavirus across China
0:03:56 and looking at outcomes and results there.
0:03:58 Our data that are emerging like this factoring
0:04:01 into your decision-making and into the decisions
0:04:03 that cancer centers across the country are making,
0:04:05 that data was of course limited,
0:04:08 but it did suggest increased morbidity,
0:04:11 even among patients who were not actively immunosuppressed.
0:04:14 How are you guys thinking about data like this
0:04:18 and also about generating data within your centers?
0:04:20 – We do think that cancer patients
0:04:24 are probably more susceptible to viruses in general.
0:04:26 They’re also more likely to get more serious complications.
0:04:29 So I think we do have to be very ginger
0:04:31 about what types of treatments we’re giving our patients.
0:04:32 And we know that for patients
0:04:35 who are at higher risk for complications,
0:04:37 we may be able to give them more support
0:04:40 in terms of medications that can maybe decrease the risk
0:04:43 of their immune system being compromised.
0:04:45 So I think it is a valid concern.
0:04:47 And I think that most of our treatments
0:04:52 can affect patients in terms of their immune system.
0:04:53 And we have to be very cognizant
0:04:56 of how we’re treating these patients.
0:04:59 – So let’s get into those kinds of clinical decisions
0:05:01 that patients are facing right now.
0:05:04 There must be an enormous amount of gray area.
0:05:07 Is there any kind of broad framework in place
0:05:10 or is it really on a case-by-case basis?
0:05:12 – We broadly categorize treatments
0:05:15 in terms of curative intent versus palliative intent.
0:05:18 Curative intent meaning that you’re initiating chemotherapy
0:05:21 or immunotherapy or any surgery, for instance,
0:05:24 to be able to cure that patient from that cancer.
0:05:27 Palliative is working as thinking about treatments
0:05:30 more in terms of improving patient symptoms
0:05:31 or helping them to live longer.
0:05:34 But we know that for the majority of these patients,
0:05:37 they won’t be able to be cured from this condition.
0:05:39 So there have been some larger frameworks
0:05:42 about saying that for patients
0:05:45 who are undergoing curative intent chemotherapy,
0:05:46 that we should go for with that
0:05:47 because the risk of recurrence
0:05:50 could be causing a great deal of harm for these patients.
0:05:52 However, for palliative patients,
0:05:54 maybe we should be a little bit more ginger
0:05:55 about starting chemotherapy,
0:05:59 which may dampen their immune system in the short run
0:06:02 while we’re facing a higher risk from coronavirus.
0:06:04 – I think almost everything we do in oncology
0:06:09 is looking at risks and benefits of various treatments.
0:06:11 And I think most decisions we make
0:06:12 are based on that calculation.
0:06:14 And what’s so interesting now
0:06:17 is you have a whole new set of risks with COVID, right?
0:06:19 Some of that’s like you take a risk
0:06:21 by walking out of your house in the morning,
0:06:23 which certainly wasn’t the case.
0:06:25 You take a risk by walking into clinic.
0:06:27 We take for granted that if someone gets sick
0:06:29 and needs to go to the hospital,
0:06:30 we have a good hospital for them,
0:06:33 but are the hospitals gonna be overloaded in three weeks?
0:06:34 If someone needs an ICU bed
0:06:36 or needed a ventilator for something,
0:06:38 is that gonna be available?
0:06:39 So, I’ve spent a lot of time
0:06:42 just trying to think about these risks,
0:06:44 a lot of which are very uncertain
0:06:46 and how those play into those treatment decisions
0:06:49 about starting someone on adjuvant therapy
0:06:52 or starting someone on palliative therapy.
0:06:54 – Several of the guideline organizations
0:06:56 that guide cancer care in this country
0:07:01 have, like ASCO, have put out relatively broad statements
0:07:06 outlining the role of coronavirus
0:07:09 factoring into decision-making
0:07:12 with respect to both curative intent
0:07:13 and palliative intent chemotherapy
0:07:16 with respect to timing of bone marrow transplantation,
0:07:20 for example, recommending that such a procedure
0:07:22 potentially be delayed for patients,
0:07:24 thinking about adjuvant therapy,
0:07:27 but most of the guidance has left a lot
0:07:28 of room for interpretation.
0:07:32 And so, I’m curious, how are you personalizing that guidance?
0:07:34 – I think ASCO has done a really nice job
0:07:38 of responding to this and putting out information,
0:07:41 but at the end of the day, at least from where I sit,
0:07:43 most of the recommendations have been
0:07:46 use your clinical judgment and take into account,
0:07:50 again, going back to that risk-benefit framework.
0:07:52 So, I’ll give you a couple examples.
0:07:55 I saw someone this week
0:07:58 who was an early-stage lung cancer patient
0:08:02 who I had seen at the end of February,
0:08:04 and we planned to give him adjuvant chemotherapy,
0:08:08 and we just had our second discussion today,
0:08:10 and we went from the conversation
0:08:12 about what’s the benefit of adjuvant chemotherapy
0:08:15 and should we go through with this in February
0:08:18 before any of us were really thinking of coronavirus,
0:08:21 and then we re-had the conversation twice
0:08:23 over the last week and a half,
0:08:24 and the framework shifted, right?
0:08:27 Like, it made sense to do at the end of February,
0:08:29 both to me and to the patient,
0:08:30 and it no longer made sense,
0:08:33 because the absolute benefit that we’re gonna see for this,
0:08:35 when you compound it with the risk of,
0:08:37 he’s gonna need to come into the office frequently,
0:08:40 it’s gonna be harder and harder for him to stay isolated,
0:08:43 what happens if he has a side effect or toxicity
0:08:44 that puts him in the hospital,
0:08:47 what are the additional risk factors for him
0:08:50 being immunosuppressed because he’s having chemotherapy,
0:08:51 it just didn’t make sense to do that.
0:08:55 Now, he was a stage 1B lung cancer, a situation,
0:08:57 and he was high risk, but it’s a situation
0:09:00 in which you would go back and forth to begin with
0:09:03 about whether to give adjuvant chemotherapy.
0:09:06 I’ve had patients on bone modifying agents,
0:09:08 these are drugs that are supportive drugs
0:09:12 that are typically used in a variety of diseases,
0:09:14 but while there’s benefit, the benefit accrues
0:09:17 over a long period of time, and I’ve pushed those off
0:09:19 because, again, I don’t know that there’s
0:09:21 a right or wrong answer, but in my judgment,
0:09:24 the risk of them stepping out of their house
0:09:27 and coming into the clinic probably doesn’t make sense.
0:09:29 – Most practitioners would probably continue
0:09:31 with the chemotherapy for patients who are young
0:09:34 and otherwise fit and doing well with treatment.
0:09:37 For patients where you’ve had a deep remission,
0:09:40 now one year, two years beyond treatment,
0:09:42 for a lot of those patients, we can probably
0:09:45 safely stop treatment at that time,
0:09:46 and hopefully the patients will continue
0:09:48 to remain in remission.
0:09:49 So it really depends on where the patient is
0:09:52 and what kind of response they’ve had,
0:09:54 but it also depends on the type of cancer they have.
0:09:56 We know that there is a significant amount
0:09:58 of heterogeneity between cancers,
0:10:00 so not all cancers are created equal by any means.
0:10:02 So in each situation, we have to kind of do
0:10:04 the risk-benefit calculus and make sure
0:10:06 that it’s in the best interest of the patient.
0:10:09 – Are questions like this coming up at our tumor boards,
0:10:13 who is the group that you’re able to engage
0:10:16 in real time on such difficult decisions
0:10:18 for individual patients?
0:10:20 – Well, Vinita, as one of my seven Twitter followers
0:10:22 you may have seen…
0:10:26 – I saw that you crowdsourced that, well done.
0:10:30 – Yeah, I crowdsourced the early stage lung cancer question
0:10:31 today.
0:10:34 We have a multi-disciplinary lung tumor board, Vinita,
0:10:36 where these questions have come up.
0:10:39 A lot of curbsiding other docs, that’s been my experience.
0:10:40 I think what’s really interesting
0:10:43 about the problems we’re facing is, you know,
0:10:46 there’s sort of the art and the science of medicine.
0:10:48 And this is really one of those circumstances
0:10:51 that the art of medicine and judgment
0:10:55 and how to apply sort of knowledge about data
0:11:00 to great areas of uncertainty really comes into play.
0:11:02 And it’s been intellectually challenging to do so.
0:11:04 – I’m glad you brought up Twitter because I’m wondering,
0:11:08 is that a viable kind of tool for you guys
0:11:12 for crowdsourcing, for even anecdotal data advice
0:11:14 decision-making in this area?
0:11:17 – I’ve personally found the discussions on Twitter
0:11:21 about this to be really helpful and really informative.
0:11:24 So, to me, yes, you know, you can only give,
0:11:26 you have to be a little bit more general
0:11:29 than you would like to be for PHI reasons, obviously.
0:11:31 But I find it very useful.
0:11:33 – I actually think that Twitter is probably the best source
0:11:34 of medical information right now,
0:11:37 as an academic and an oncologist.
0:11:40 The majority of my data that I’m actually receiving,
0:11:43 I’m receiving in real time from my Twitter feed,
0:11:46 as opposed to waiting for publications to come out.
0:11:48 So it’s actually been very, very helpful
0:11:50 to have access to Twitter.
0:11:52 And it’s just been a tremendous communication tool
0:11:53 from experts around the country
0:11:55 and in the world in general.
0:11:57 We’ve been using our tumor boards
0:11:59 to discuss a lot of these cases
0:12:02 as we alluded to earlier, that the data is very gray.
0:12:04 We really don’t have a lot of information
0:12:06 to base these decisions on.
0:12:07 There have been consensus statements
0:12:10 that have been put out into large publications
0:12:12 from thought leaders across the world.
0:12:15 And we’ve been using those as a framework
0:12:18 by which to make our decisions at Stanford as well.
0:12:21 But to still very much a gray area is important
0:12:23 that we have employees share decision-making
0:12:26 with our patients to make sure that they’re also,
0:12:28 feel that they’re a part of this conversation.
0:12:31 – It strikes me that a lot of the decisions
0:12:32 that you’re talking about making,
0:12:35 you already are at a place of understanding
0:12:37 to a large degree what you’re dealing with,
0:12:39 what kind of cancer, how it tends to behave.
0:12:43 What about the patients that just found a lump
0:12:46 and were coming to you for like the very first step?
0:12:48 How do you, what are the guidelines there?
0:12:52 Like begin, wait it out for two weeks, you know?
0:12:54 – The answer to this in general will really vary
0:12:56 depending on where you are in the country,
0:12:58 what kind of health system you’re in right now
0:12:59 and the where we are in the pandemic as well.
0:13:01 ‘Cause we know that resources are shifting
0:13:06 on a daily basis based on local prevalence rates.
0:13:09 So while I think it’s true that most non-essential
0:13:11 procedures and surgeries are being postponed,
0:13:15 the suspicion for cancer does increase
0:13:18 the prioritization of certain scans or procedures.
0:13:22 So for a newly diagnosed or a new breast mass
0:13:25 that you may feel in the shower, for instance,
0:13:28 that would actually take prioritization to have that worked up.
0:13:32 For men who have an increase in PSA
0:13:34 over a slow period of time,
0:13:37 they probably don’t need a prostate biopsy right away.
0:13:40 So it really will vary on the type of cancer
0:13:42 and the type of patient as well.
0:13:45 But in general, patients with cancer suspicion
0:13:48 will probably be at a higher prioritization
0:13:50 for getting their treatment done.
0:13:54 – So at Flatiron Health, among our practices
0:13:57 which use our electronic health record, ONCO EMR,
0:14:00 we’re able to track patient volume.
0:14:05 And we saw last week a 22% drop in office visits
0:14:09 across the network of practices
0:14:13 that also included a 16% drop in visits
0:14:16 related to chemotherapy all in the past week.
0:14:19 I think those are partially shock of the system.
0:14:21 Let’s reevaluate and see who needs to come in
0:14:23 and who doesn’t, but it was pretty impactful.
0:14:26 I mean, our numbers across our network
0:14:27 are very, very consistent.
0:14:30 And then there was just this big drop last week.
0:14:31 I think a lot of that is just gonna be,
0:14:33 whoa, hold on, we have to figure out what we’re doing.
0:14:35 I don’t think necessarily you’re gonna see
0:14:37 that much drop in chemotherapy,
0:14:39 but I think there’s gonna be a lot of really interesting data
0:14:41 that’s gonna come out of that
0:14:45 to try to understand how this impacted cancer outcomes.
0:14:47 – And to your point, Bobby,
0:14:51 about kind of this being a sort of unprecedented shock
0:14:53 to the oncology care system
0:14:57 for us to really see what kind of an impact happens
0:14:59 on visit volume and treatment volume.
0:15:03 And some of that may even extend to outcomes
0:15:08 and it may be a really sort of fine grain sensitivity analysis
0:15:12 that we sort of have an opportunity to later look back at
0:15:14 and say, well, what really happened
0:15:18 if surgery was delayed by this period of time
0:15:19 and how did outcomes change?
0:15:21 And what really happened if adjuvant therapy
0:15:23 was delayed by this period of time?
0:15:25 How did outcomes change?
0:15:28 I think, I hope that to some extent,
0:15:31 some of that may be a silver lining
0:15:34 in terms of learning from this crisis.
0:15:35 – The other sort of interesting thing
0:15:39 that’s come out of this is it makes you spend a lot of time
0:15:41 thinking how much you really need,
0:15:45 things that you thought you really needed, right?
0:15:49 Like, usually this patient comes in and gets blood drawn
0:15:52 and yeah, I’m gonna do this telemedicine visit
0:15:53 and we’re gonna skip the blood draw
0:15:55 and I find myself saying, don’t worry,
0:15:57 we can do it again in three to six months,
0:15:58 which sort of raises the question,
0:16:01 do they really need that blood draw to begin with?
0:16:04 – Yeah, or that scan or that physical exam.
0:16:07 We’ve all felt sort of the sadness
0:16:11 when we hear a patient describe their five-hour drive
0:16:14 and then their hour-long wait in the waiting room
0:16:16 and then their five-hour drive back
0:16:18 because it’s crazy to try to get a hotel room
0:16:19 on the day of their visit
0:16:22 and this kind of logistical nightmare
0:16:26 that many patients undergo in order to seek cancer care
0:16:30 or seek second opinions or seek clinical trial evaluation
0:16:32 and I think we’ve all wondered, well,
0:16:35 could some of this be happening more efficiently
0:16:37 and in a more patient-centric way
0:16:40 if we were to embrace technology in various ways
0:16:44 and sometimes a crisis is an opportunity for us
0:16:46 to embrace that tech stack
0:16:48 and I think we’re all seeing it happen.
0:16:51 I’ve been sort of floored and amazed
0:16:54 at how much of the Stanford oncology clinics
0:16:58 are now sort of operating in the telemedicine sphere.
0:17:00 I’d love to hear how you guys are managing this.
0:17:03 Which patients are you bringing into clinic?
0:17:05 Which are you managing via telemedicine?
0:17:07 – I mean, I think the whole remote care
0:17:10 telemedicine virtual medicine,
0:17:11 I did my first telemedicine session
0:17:14 and I finished it and my thought was,
0:17:15 where have you been all my life?
0:17:19 – Your patient might have had the same thoughts.
0:17:22 – Yeah, right, like that was easy.
0:17:25 The easy answer is routine follow-up.
0:17:27 So the patients who were coming in for routine follow-ups
0:17:29 who didn’t want to reschedule or push back,
0:17:31 I’ve done those over telemedicine
0:17:33 and that’s been relatively easy
0:17:36 and relatively straightforward.
0:17:38 I’ve also had a couple other patients
0:17:40 who weren’t routine follow-up
0:17:42 but I wanted to try to keep out of the office
0:17:44 thinking about a couple of patients, for example,
0:17:47 with a disease called chronic lymphocytic leukemia
0:17:49 who were on relatively new therapies,
0:17:51 were coming in to get their blood counts checked
0:17:53 so they weren’t just routine follow-ups
0:17:56 but given the changing circumstances,
0:17:59 I felt relatively comfortable doing a telemedicine visit,
0:18:00 making sure they’re okay
0:18:03 and pushing back their lab results for a few weeks
0:18:05 where you obviously can’t do it
0:18:07 is on people who need a treatment.
0:18:11 So people who need medicines to boost up their blood counts
0:18:14 to keep their blood counts from getting too low,
0:18:15 there are ways you can give those at home
0:18:18 but for patients who are getting it in the office,
0:18:21 sometimes it’s just not easy to get that quickly done
0:18:26 and then the regulations around using FaceTime and Skype
0:18:29 and other non-HIPAA compliant platforms
0:18:31 has been lifted at least for the time being.
0:18:33 So I’ve had a couple of circumstances
0:18:36 where I’ve just FaceTimed patients to do this.
0:18:38 – We’ve really dramatically scaled up
0:18:41 the virtual clinics in our clinics in the last two weeks
0:18:42 which is quite ironic
0:18:44 ’cause we’ve actually had virtual capabilities
0:18:45 for over a year now
0:18:48 but it’s literally taking a pandemic to do this.
0:18:49 The utilization of virtual
0:18:52 was around five to 10% of our clinic visits
0:18:53 over the past year
0:18:54 but now in the last week
0:18:56 is now greater than 60% of our visits
0:18:57 are actually now all virtual
0:18:59 which is quite extraordinary.
0:19:04 Yeah, and we have this alignment for the first time actually
0:19:05 where we actually have an alignment
0:19:08 between providers, patients and now even payers
0:19:13 as CMS changed their laws this past week
0:19:15 to allow for reimbursement for televisits
0:19:17 and virtual medicine.
0:19:21 So that’s really changed the landscape completely
0:19:22 and so now we’re seeing a huge rise
0:19:25 in our ability to deliver virtual care.
0:19:27 – So we had a podcast recently
0:19:30 where we talked quite a bit about using virtual medicine
0:19:32 and telemedicine tools for primary care
0:19:36 and sort of triaging symptoms from your home.
0:19:39 Are there particular pressure points
0:19:42 that you’re noticing from the specialist point of view
0:19:44 where things aren’t working so well,
0:19:45 where there are sticking points
0:19:47 or where the data flow gets messed up?
0:19:49 – Part of the thing in oncology
0:19:52 is you administer therapies to patients
0:19:53 and a lot of those therapies
0:19:57 it’s sort of hard to do in a remote setting.
0:20:00 I think from the oncology standpoint, that’s a barrier.
0:20:03 The other area which I’ve sort of seen
0:20:05 and again this has been in a limited experience
0:20:09 is there are often difficult discussions you have
0:20:10 and I think we’re all accustomed
0:20:14 to delivering those difficult discussions in person
0:20:16 and the ability to have physical contact
0:20:20 but I think that’s been a tough part of remote oncology.
0:20:21 – Wow, yeah.
0:20:24 – So much of oncology is an art form as you were saying
0:20:27 and it’s really our ability to connect to a patient
0:20:28 which makes oncology so special
0:20:30 and which is why so many of us went into this field
0:20:31 in the first place.
0:20:34 But it’s very difficult to do that virtually
0:20:36 as much as I would love an emoji.
0:20:38 I think an embrace after giving someone good news
0:20:41 is much more wanted by us
0:20:46 and we also know that the physical exam, as you were saying,
0:20:48 is also very limited for these virtual visits.
0:20:50 We do have some limitations
0:20:52 especially where the physical exam
0:20:53 can be a little bit more important
0:20:56 such as gynecological cancers
0:20:58 like endometrial cancer or cervical cancer.
0:20:59 – What could be better?
0:21:03 Like if you had to brainstorm a feature list
0:21:07 for the platforms that you’ve tried, what would help?
0:21:08 – On our current platform,
0:21:10 we can’t share screens nearly as easily
0:21:14 so I was trying to tell a patient about a lung nodule
0:21:16 and he wanted to see it actually on his CT scan.
0:21:18 So I actually had to take a mirror
0:21:22 and show him his lung scans
0:21:24 through the reflection on the mirror
0:21:26 which I thought was extraordinary in 2020
0:21:28 that we can’t do this quite yet.
0:21:30 – How about the sharing of information
0:21:33 like provider to provider or specialist to specialist?
0:21:34 That’s something that our partner Julie Yu
0:21:36 brought up on the last podcast
0:21:39 as being still not seamless with the data flow
0:21:41 of these telemedicine tools.
0:21:44 – Well, I mean, I’ll give you an example today
0:21:46 that happened to me as one of my patients
0:21:49 who I didn’t think I was gonna need to examine
0:21:51 said, “Oh, I have this thing on my back”
0:21:53 and turned around and tried to show me this thing
0:21:55 on his back and it was,
0:21:57 which as an aside, there have been a lot
0:22:00 of sort of comical technology related things
0:22:02 that have happened in the last week and a half too.
0:22:04 – Like what, like I can’t even,
0:22:06 would you put your phone on your cabinet
0:22:08 and like turn around and take your shirt off?
0:22:10 I can’t even really imagine how that.
0:22:12 – Well, like this was one trying to turn around
0:22:15 and show that my patient trying to show me a picture
0:22:17 of his lower back and calling his wife in
0:22:19 and not being able to see where he was.
0:22:22 Another patient who just wasn’t really used
0:22:24 to using the phone on his camera
0:22:27 and he kept putting his camera up against his ear
0:22:29 so I could see the inside of his ear.
0:22:33 But not that, you assume that everyone
0:22:35 in the world uses technology like you do
0:22:39 and you quickly find out that is not the case.
0:22:43 Like people who aren’t sure what to do with a hyperlink.
0:22:45 So that’s been sort of interesting,
0:22:47 but I’ve had some nice laughs with my patient
0:22:50 around this as well.
0:22:53 – So some of this are sort of growing pains
0:22:56 and rollout pains, but maybe in the future,
0:22:59 if a cancer patient was expecting a certain fraction
0:23:02 of their visits to be over telehealth,
0:23:05 maybe that adoption curve would look different.
0:23:08 – Yes, so I mean, I’ll just give you one example
0:23:09 for a feature that would have been nice.
0:23:10 So this patient who I just told you about
0:23:12 who had this thing on his back,
0:23:14 I couldn’t get a clear enough picture on the video.
0:23:17 He actually took a picture of it with his camera
0:23:18 and then emailed it to me.
0:23:22 I looked at it, I thought I knew what it probably was.
0:23:25 I then went through a long and arduous process
0:23:27 of communicating with his dermatologist
0:23:29 who he was supposed to see next week
0:23:31 and sending him the image.
0:23:32 Boy, wouldn’t it have been nice
0:23:34 if I could have taken the image
0:23:36 right from the telehealth platform,
0:23:39 sent it over to his dermatologist
0:23:42 and messaged his dermatologist on the same platform.
0:23:43 Hey, can you take a look at this
0:23:46 and let me know what you think?
0:23:48 The biggest problem from my perspective to solve,
0:23:50 and this is not just telehealth,
0:23:53 but I think everything is, you know,
0:23:56 real time or fast communication between clinicians,
0:23:59 whether it’s colleagues or second opinions
0:24:01 or docs you refer to.
0:24:04 That’s the biggest pain point for me,
0:24:07 which ultimately could be solved partially with this.
0:24:10 A couple of the observations that I had
0:24:14 watching some of these telehealth visits take place
0:24:18 were just kind of how open and comfortable
0:24:22 a lot of the patients seemed chatting over a video visit.
0:24:25 My sense is that some of that is because applications
0:24:28 like FaceTime and other video chatting applications
0:24:29 are just so much more prevalent today
0:24:32 that a lot of patients don’t feel like
0:24:35 it’s quite as awkward as you might have anticipated.
0:24:39 It was actually interesting to get a glimpse
0:24:42 into how they’re functioning and what they’re doing
0:24:44 and the fact that they’re running in from the kitchen
0:24:46 or, you know, just you kind of get a sense, actually,
0:24:49 of a patient’s mobility and comfort level
0:24:53 with their ADLs, activities of daily living
0:24:54 in a way that you can’t sometimes get
0:24:56 when they’re sitting on an exam table.
0:24:59 So I think it’s been interesting to see
0:25:03 that we might actually learn about patients
0:25:06 in a way that is hard to do when they come to the clinic.
0:25:09 Yeah, you know, it’s funny to say that.
0:25:12 I mean, I’ve found one of the really useful things
0:25:15 is seeing people in their own environments and in their homes.
0:25:18 One thing I always like to do with patients
0:25:22 is I’ll ask them to bring in pictures of themselves
0:25:24 either when they were younger or before they were sick.
0:25:28 And I was telehealthing with one patient
0:25:30 and she was sort of sitting at a desk and behind her,
0:25:34 she had like a million family photos all hanging on the wall.
0:25:36 And I was like, and I didn’t do it,
0:25:38 but I was so tempted to say, hey, could we, you know,
0:25:42 pull a couple of those off and let’s take a look at them.
0:25:45 But you do, you really get insight that you don’t.
0:25:47 And I’ve had like, I literally had two patients,
0:25:49 30 seconds into the conversation, say to me,
0:25:51 oh my God, I forgot to put on makeup.
0:25:54 And, you know, you just realize you see people different
0:25:57 than you see them when they come into the office.
0:25:59 One space that we’ve all heard a lot of discussion
0:26:03 about actually in the context of coronavirus therapies
0:26:06 are clinical trials that are now actively enrolling.
0:26:09 And I think a lot of people have started thinking
0:26:10 about what a clinical trial is
0:26:13 and have heard the word more than they might have before.
0:26:16 But for cancer patients, this is the norm, right?
0:26:18 A lot of our cancer patients are always thinking
0:26:23 about a trial in the future or they might be on a trial now.
0:26:26 We’d love to hear how clinical trial operations
0:26:29 are affected by shelter at home orders
0:26:32 for so many of our non-essential workforce.
0:26:35 How is that playing out for patients on trials
0:26:38 or patients considering trials?
0:26:40 The shelter in place is obviously
0:26:43 hampered enrollment considerably.
0:26:45 We’ve had a tremendous decrease in enrollment
0:26:46 over the last couple of weeks,
0:26:48 which is very understandable.
0:26:50 Patients just don’t want to come to the hospital
0:26:51 nearly as much.
0:26:53 Adding to that is that a lot of trials
0:26:56 are actually holding new recruitment to trials as well.
0:26:59 So a lot of the crew was being held right now.
0:27:00 For patients currently on trial,
0:27:02 they are allowed to continue on treatment
0:27:04 and they are encouraged to do so.
0:27:06 They are allowing for more deviations,
0:27:09 meaning that patients can skip treatments
0:27:11 if they feel that they need to
0:27:13 in order to protect themselves from the virus.
0:27:16 So we’re starting to see that sponsors or trials
0:27:19 are a lot more lenient than they were in the past.
0:27:22 A lot of the trials that are with oral medications
0:27:24 are still being continued
0:27:27 and these sponsors are also feeling a lot more lenient
0:27:29 about shipping drug home
0:27:31 so that patients don’t have to come into the hospital.
0:27:34 I also agree that this is going to cause us to
0:27:37 reconsider the way that we do a lot of our clinical trials.
0:27:39 Is it really necessary that you get
0:27:43 that certain esoteric lab on day 52 of a clinical trial
0:27:45 and make the patient come in for four hours away to do that?
0:27:47 I think this will make us realize
0:27:49 that a lot of the things that we’re doing
0:27:52 are probably not as important as we used to think they are.
0:27:55 – The FDA announced that they’re working
0:27:59 on providing guidance to sponsors and trial sites
0:28:02 to enable sufficient regulatory flexibility
0:28:05 to allow trials to continue through this period
0:28:06 to the extent possible,
0:28:09 while of course keeping patient safety paramount.
0:28:12 What are some of the tactical ways
0:28:15 in which you think this guidance could play out
0:28:18 and in which you think there might be more flexibility
0:28:20 than there was before?
0:28:23 – I think the flexibility ultimately helps.
0:28:26 There is so much concern about not following protocols
0:28:31 exactly to the T and deviations to that.
0:28:34 But I think that flexibility is gonna get people
0:28:37 ultimately more comfortable with having patients on trial
0:28:38 during this time.
0:28:43 To me, it’s certainly it’s understandable
0:28:44 why things are dropping off.
0:28:47 I think it’s also in many ways tragic.
0:28:50 We at baseline don’t put enough patients on clinical trials.
0:28:53 It’s such an urgent need and it’s just disappointing
0:28:56 even if understandable to see why that’s dropping off.
0:28:58 And you probably saw, I think Pfizer made an announcement
0:28:59 that they’re stopping accrual
0:29:01 except for life-threatening conditions.
0:29:03 I don’t know if life-threatening applied
0:29:05 to every cancer trial that they’re doing or not.
0:29:08 For trials where, assuming you have enough staff
0:29:10 to keep taking care of patients,
0:29:13 if you have a trial that doesn’t require visits
0:29:15 outside of the standard of care,
0:29:18 I’d hope we’d be able to see those continue.
0:29:22 One thing that was really personally very exciting to me
0:29:24 is we have a lot, community oncology
0:29:26 does a lot of clinical trials,
0:29:28 something that I think not everyone appreciates.
0:29:32 And we’ve seen a lot of continued accrual to trials.
0:29:34 We work very closely with one particular trial
0:29:37 that we’ve helped do data collection for.
0:29:41 And we’ve seen practices even in the last week
0:29:44 accrue four, five or six patients to this.
0:29:47 Docs, despite adversity, get that clinical trials
0:29:50 are important and are continuing to try to do it,
0:29:51 even in difficult times.
0:29:53 – It’s interesting because, going into this,
0:29:56 I sort of, as an outsider, sort of naively thought
0:30:00 that the broadest level, the advice
0:30:02 or the kind of thinking would be pause
0:30:05 what we can pause safely.
0:30:07 But it actually sounds like what you’re saying
0:30:11 is keep doing everything that we can keep doing safely.
0:30:13 It’s more the spirit.
0:30:15 That’s my perspective, especially,
0:30:17 I mean, it also depends on the trial, right?
0:30:19 So if you’re doing a clinical trial,
0:30:21 which are often the case in cancer,
0:30:24 whether it’s a phase one trial or a phase two trial
0:30:27 for people with bad cancers who have run out of options,
0:30:29 it’s difficult to continue those.
0:30:31 But I think it’s appropriate a lot of the time
0:30:33 to think about how can we make it work.
0:30:37 – We are doing a international cancer registry
0:30:40 right now on patients with coronavirus.
0:30:42 And this was an effort that was largely led
0:30:44 through Twitter, actually, by recruiting other physicians
0:30:47 from other institutions to capture all this data.
0:30:50 And I do think that clinical trial data,
0:30:52 especially randomized clinical trials,
0:30:55 are gonna be more difficult to do in the current era
0:30:57 because of the regulation.
0:30:58 There should be an importance placed
0:31:00 on what we call real world evidence.
0:31:03 And this type of data is gonna be very informative
0:31:05 in the next several months as well,
0:31:06 as we’re gonna get limited data
0:31:08 from randomized clinical trials.
0:31:10 – Let’s sort of go back to where we started
0:31:13 and think about what happens to oncology as a whole
0:31:18 when it’s forced in this moment to go so virtual.
0:31:19 What do you think is gonna stick?
0:31:23 And what do you think we will let fall by the wayside
0:31:26 when we finally get to move out of this moment?
0:31:29 – I do think that virtual clinics are here to stay.
0:31:32 I also think that we’re gonna see a large shift away
0:31:36 from hospital-based care and more towards home-based care.
0:31:39 Do you really need your infusion at Stanford
0:31:41 or at your cancer center,
0:31:44 as opposed to the confines of your living room?
0:31:47 I think if you look at certain examples,
0:31:49 for drugs that we use in lymphoma,
0:31:51 for instance, a drug called Rituximab,
0:31:54 it’s an IV medication that has now been formulated
0:31:56 to be subcutaneous.
0:31:57 And you can imagine a scenario
0:32:01 where you had a digital safety lock on that syringe
0:32:04 that could be activated by your provider
0:32:07 if after a virtual consultation to make sure
0:32:10 that your lab’s look okay and that you were feeling okay.
0:32:12 So I think a lot of the stuff that we’re doing right now
0:32:14 in the clinics can certainly be done at home,
0:32:19 kind of furthering the capabilities of virtual medicine.
0:32:20 – What’s the incentive to keep doing that
0:32:23 after the coronavirus goes truly away?
0:32:25 – Patients in general actually prefer this.
0:32:28 It’s amazing that after these virtual consultations,
0:32:29 I’ll often tell a patient that,
0:32:31 “Well, I’ll see you back in three months,
0:32:32 hopefully here at Stanford.”
0:32:33 And they say, “Well, Doc, actually,
0:32:35 this worked out pretty well.
0:32:37 Why don’t I just see you back on my cell phone
0:32:38 in three months instead?”
0:32:41 I do think that we’re gonna see a greater use
0:32:44 of digital health and public health interventions as well,
0:32:48 and the rise of public-private partnerships.
0:32:50 If you look at the countries that were the most successful
0:32:53 in containing this epidemic,
0:32:55 they’re all countries that employ technology
0:32:58 as a very large part of their response.
0:33:00 You look at South Korea using cell phone data
0:33:04 to be able to contact tracing for patients
0:33:06 who are infected with coronavirus.
0:33:08 Even Russia was using artificial intelligence
0:33:12 and facial recognition to be able to enforce their quarantine,
0:33:14 not suggesting that we do that by any means.
0:33:16 But then you can even look to China
0:33:18 that was using artificial intelligence
0:33:22 to be able to diagnose COVID just from chest x-rays.
0:33:24 So I think that we’re gonna start seeing
0:33:27 a lot more digital health and public health infrastructure,
0:33:30 and I think that’s another thing that’s here to stay as well.
0:33:32 – Specifically around telemedicine,
0:33:33 the genie’s out of the bottle,
0:33:36 and it’s gonna be hard to sort of put it back in.
0:33:38 One of the things that CMS did
0:33:40 that I think was really, really helpful
0:33:41 was expanding the number of codes
0:33:43 that you could use for telemedicine.
0:33:45 I like to think that’s gonna continue
0:33:48 because that just made the whole process
0:33:51 much, much easier for clinicians to do.
0:33:53 I like to think that all of us having
0:33:56 to go through the experience of really asking,
0:34:00 do we really need these things that we always think we need?
0:34:01 Just like sort of value-based care
0:34:03 has pushed us in a direction
0:34:05 to second-guess things that we used to do.
0:34:09 I hope that this does as well.
0:34:10 And then lastly, one of the things
0:34:14 that this whole episode has caused me to reflect on.
0:34:16 I’m fortunately healthy, my family’s healthy,
0:34:19 and I was basically, we were all given news
0:34:21 a couple of weeks ago that you have to stay at home,
0:34:24 you can’t go out, your life’s gonna be disrupted,
0:34:26 and if you get this disease,
0:34:28 there’s like, for me and my age group,
0:34:31 there’s a couple percent chance that I’m gonna die,
0:34:33 and that was really, really hard news
0:34:35 for me to take as an individual.
0:34:37 And in my job as an oncologist,
0:34:39 I give people news 10 times worse than that
0:34:43 every single day, and they deal with it a lot better
0:34:46 than I have dealt with this.
0:34:48 So I like to think that for all of us
0:34:49 who’ve been lucky enough to be healthy,
0:34:51 it gives us a little bit of perspective
0:34:52 of what our patients go through.
0:34:53 That’s wonderful.
0:34:56 The silver lining, in my view,
0:34:58 from sort of a technology perspective,
0:35:02 is that it’s the pressure test of unprecedented scale
0:35:07 for our system to navigate how to incorporate technology
0:35:08 in different aspects of care,
0:35:10 how to keep in touch with patients
0:35:12 when they can’t come into the clinic,
0:35:14 how to make complex decisions
0:35:16 that require coordination in real time
0:35:19 with uncertain data between different specialists,
0:35:21 because this is a time when,
0:35:23 under this type of real pressure,
0:35:24 that’s when these future lists are generated,
0:35:26 and that’s when we realize what we need,
0:35:28 and what we realize we need now.
0:35:30 And so I think that this pressure test
0:35:35 is just going to actually be an incredible learning opportunity
0:35:37 for a variety of sectors of digital health.
0:35:40 The other piece that I think is interesting,
0:35:43 kind of zooming out of oncology in particular,
0:35:45 is just the increased awareness
0:35:46 that’s occurred for diagnostics
0:35:48 and infectious disease therapeutics.
0:35:53 I think it’s given our public, our funding agencies,
0:35:57 companies, investors, everyone across the board,
0:35:58 a deepened level of appreciation
0:36:02 for how important anti-infective agents
0:36:04 and preventive agents really are.
0:36:09 And so I hope we’ll see renewed investment globally
0:36:10 in technology in that domain.
0:36:11 – That’s really inspiring.
0:36:13 Well, thank you so much for all joining us
0:36:15 on the A16Z podcast,
0:36:16 and thank you for everything you’re doing
0:36:18 for your patients every day.
0:36:19 – Thank you so much, guys.
0:36:23 (upbeat music)
0:36:33 [BLANK_AUDIO]
0:00:07 We’re talking today about what is happening to oncology
0:00:09 and to patients going through cancer treatment
0:00:11 during the outbreak of coronavirus.
0:00:12 How treatment is affected,
0:00:15 what kind of clinical decisions oncologists
0:00:17 are having to make, what kind of new tools
0:00:20 and what happens to oncology as a whole
0:00:23 when it’s forced in this moment to go so virtual.
0:00:25 Joining myself and Venita Agarwalha,
0:00:28 physician and general partner at A16Z
0:00:30 are Dr. Bobby Green, community oncologist
0:00:33 and chief medical officer at Flatiron Health,
0:00:34 who is the first boy seal here,
0:00:38 and Dr. Sumit Shah, oncologist and head of digital health
0:00:40 at the Stanford Cancer Center.
0:00:43 We’re here today because coronavirus is now disrupting
0:00:46 the entire healthcare system,
0:00:48 not just because of the burden of dealing
0:00:49 with the actual disease itself,
0:00:50 but because of everything else
0:00:52 that’s had to grind to a halt.
0:00:56 One of those areas where we really worry about things
0:00:57 coming to a total stop like that
0:00:59 is of course cancer treatment,
0:01:01 which can often feel like a race against the clock,
0:01:04 even under the best conditions.
0:01:07 So can we just start by talking about the biggest issues
0:01:09 that your cancer patients are facing right now?
0:01:12 – I’ve been sort of, I guess, surprised
0:01:15 how much more resilience I’ve actually seen
0:01:17 among a lot of my patients.
0:01:19 And maybe it’s just because they’ve lived
0:01:20 through so much uncertainty
0:01:23 and gone through so much as part of their diagnoses
0:01:26 that this is just one more thing.
0:01:29 But I do think people have been remarkably resilient
0:01:33 and in fact, in some ways a lot more so
0:01:35 and maybe more laid back about this
0:01:38 than some of my healthy friends and colleagues
0:01:41 who haven’t had to deal with any health crisis.
0:01:42 There’s been a little bit of confusion
0:01:45 about what does it mean for my treatments
0:01:46 and uncertainty about timing,
0:01:47 ’cause I think none of us really know
0:01:48 how long is this gonna last
0:01:51 and how long is the world gonna look like this.
0:01:54 And then also the other thing I’ve sort of seen,
0:01:57 and fortunately I haven’t had any patients
0:01:59 that I know of who have been laid off.
0:02:03 But I think uncertainty about jobs and people,
0:02:04 most people have their health insurance,
0:02:07 as we all know, if they’re not on Medicare
0:02:09 through their place of employment.
0:02:11 And that’s a concern as well.
0:02:13 – Yeah, I totally echo what you said about resilience, Bobby.
0:02:16 I had a patient last week who told me,
0:02:19 who told our team that they can empathize
0:02:21 with what everybody’s going through
0:02:23 because it’s exactly what they’ve felt like
0:02:24 every time they had chemotherapy,
0:02:27 that they’re suddenly susceptible to infection
0:02:29 and that they have to be careful.
0:02:31 And that was like their dominant reflection
0:02:33 is that I understand why everyone is afraid.
0:02:36 And I’ve felt that fear myself,
0:02:41 which was an incredibly sort of empathic
0:02:43 and resilient thing for somebody to say
0:02:45 you could have been worried entirely about their own care.
0:02:47 – It feels like from the outside,
0:02:49 you’d imagine that would almost double
0:02:51 that you’d get sort of extra doses of that fear
0:02:54 instead of almost being like inoculated against it
0:02:55 because you’ve gotten so used to it.
0:02:57 That’s really inspiring.
0:02:58 – Yeah, I will agree with you guys
0:03:00 that I think most of our patients
0:03:01 have been incredibly resilient
0:03:03 and understanding of the current time.
0:03:05 But I’ve also had a fair number of patients tell me,
0:03:08 Dr. Shaw, my cancer can’t shelter in place.
0:03:09 What do I do right now?
0:03:12 Which is a very poignant point as well.
0:03:14 So I think a lot of the patients are wondering
0:03:16 about the timing of chemotherapy.
0:03:17 Should I initiate chemotherapy?
0:03:19 Should I delay chemotherapy?
0:03:21 What are the risks of doing so?
0:03:23 Am I going to put my body at higher jeopardy
0:03:26 for becoming immunocompromised?
0:03:28 Or am I going to leave my body at higher risk
0:03:30 for this coming back in the future?
0:03:33 So these are very difficult decisions to kind of make.
0:03:34 And we don’t have a whole lot of data
0:03:37 to help us support that decision-making capacity.
0:03:39 So a lot of this is done on a case-by-case basis.
0:03:44 – I think a lot of providers are discussing the Lancet paper
0:03:49 about a relatively small cohort of 18 cancer patients
0:03:52 who got infected with coronavirus across China
0:03:56 and looking at outcomes and results there.
0:03:58 Our data that are emerging like this factoring
0:04:01 into your decision-making and into the decisions
0:04:03 that cancer centers across the country are making,
0:04:05 that data was of course limited,
0:04:08 but it did suggest increased morbidity,
0:04:11 even among patients who were not actively immunosuppressed.
0:04:14 How are you guys thinking about data like this
0:04:18 and also about generating data within your centers?
0:04:20 – We do think that cancer patients
0:04:24 are probably more susceptible to viruses in general.
0:04:26 They’re also more likely to get more serious complications.
0:04:29 So I think we do have to be very ginger
0:04:31 about what types of treatments we’re giving our patients.
0:04:32 And we know that for patients
0:04:35 who are at higher risk for complications,
0:04:37 we may be able to give them more support
0:04:40 in terms of medications that can maybe decrease the risk
0:04:43 of their immune system being compromised.
0:04:45 So I think it is a valid concern.
0:04:47 And I think that most of our treatments
0:04:52 can affect patients in terms of their immune system.
0:04:53 And we have to be very cognizant
0:04:56 of how we’re treating these patients.
0:04:59 – So let’s get into those kinds of clinical decisions
0:05:01 that patients are facing right now.
0:05:04 There must be an enormous amount of gray area.
0:05:07 Is there any kind of broad framework in place
0:05:10 or is it really on a case-by-case basis?
0:05:12 – We broadly categorize treatments
0:05:15 in terms of curative intent versus palliative intent.
0:05:18 Curative intent meaning that you’re initiating chemotherapy
0:05:21 or immunotherapy or any surgery, for instance,
0:05:24 to be able to cure that patient from that cancer.
0:05:27 Palliative is working as thinking about treatments
0:05:30 more in terms of improving patient symptoms
0:05:31 or helping them to live longer.
0:05:34 But we know that for the majority of these patients,
0:05:37 they won’t be able to be cured from this condition.
0:05:39 So there have been some larger frameworks
0:05:42 about saying that for patients
0:05:45 who are undergoing curative intent chemotherapy,
0:05:46 that we should go for with that
0:05:47 because the risk of recurrence
0:05:50 could be causing a great deal of harm for these patients.
0:05:52 However, for palliative patients,
0:05:54 maybe we should be a little bit more ginger
0:05:55 about starting chemotherapy,
0:05:59 which may dampen their immune system in the short run
0:06:02 while we’re facing a higher risk from coronavirus.
0:06:04 – I think almost everything we do in oncology
0:06:09 is looking at risks and benefits of various treatments.
0:06:11 And I think most decisions we make
0:06:12 are based on that calculation.
0:06:14 And what’s so interesting now
0:06:17 is you have a whole new set of risks with COVID, right?
0:06:19 Some of that’s like you take a risk
0:06:21 by walking out of your house in the morning,
0:06:23 which certainly wasn’t the case.
0:06:25 You take a risk by walking into clinic.
0:06:27 We take for granted that if someone gets sick
0:06:29 and needs to go to the hospital,
0:06:30 we have a good hospital for them,
0:06:33 but are the hospitals gonna be overloaded in three weeks?
0:06:34 If someone needs an ICU bed
0:06:36 or needed a ventilator for something,
0:06:38 is that gonna be available?
0:06:39 So, I’ve spent a lot of time
0:06:42 just trying to think about these risks,
0:06:44 a lot of which are very uncertain
0:06:46 and how those play into those treatment decisions
0:06:49 about starting someone on adjuvant therapy
0:06:52 or starting someone on palliative therapy.
0:06:54 – Several of the guideline organizations
0:06:56 that guide cancer care in this country
0:07:01 have, like ASCO, have put out relatively broad statements
0:07:06 outlining the role of coronavirus
0:07:09 factoring into decision-making
0:07:12 with respect to both curative intent
0:07:13 and palliative intent chemotherapy
0:07:16 with respect to timing of bone marrow transplantation,
0:07:20 for example, recommending that such a procedure
0:07:22 potentially be delayed for patients,
0:07:24 thinking about adjuvant therapy,
0:07:27 but most of the guidance has left a lot
0:07:28 of room for interpretation.
0:07:32 And so, I’m curious, how are you personalizing that guidance?
0:07:34 – I think ASCO has done a really nice job
0:07:38 of responding to this and putting out information,
0:07:41 but at the end of the day, at least from where I sit,
0:07:43 most of the recommendations have been
0:07:46 use your clinical judgment and take into account,
0:07:50 again, going back to that risk-benefit framework.
0:07:52 So, I’ll give you a couple examples.
0:07:55 I saw someone this week
0:07:58 who was an early-stage lung cancer patient
0:08:02 who I had seen at the end of February,
0:08:04 and we planned to give him adjuvant chemotherapy,
0:08:08 and we just had our second discussion today,
0:08:10 and we went from the conversation
0:08:12 about what’s the benefit of adjuvant chemotherapy
0:08:15 and should we go through with this in February
0:08:18 before any of us were really thinking of coronavirus,
0:08:21 and then we re-had the conversation twice
0:08:23 over the last week and a half,
0:08:24 and the framework shifted, right?
0:08:27 Like, it made sense to do at the end of February,
0:08:29 both to me and to the patient,
0:08:30 and it no longer made sense,
0:08:33 because the absolute benefit that we’re gonna see for this,
0:08:35 when you compound it with the risk of,
0:08:37 he’s gonna need to come into the office frequently,
0:08:40 it’s gonna be harder and harder for him to stay isolated,
0:08:43 what happens if he has a side effect or toxicity
0:08:44 that puts him in the hospital,
0:08:47 what are the additional risk factors for him
0:08:50 being immunosuppressed because he’s having chemotherapy,
0:08:51 it just didn’t make sense to do that.
0:08:55 Now, he was a stage 1B lung cancer, a situation,
0:08:57 and he was high risk, but it’s a situation
0:09:00 in which you would go back and forth to begin with
0:09:03 about whether to give adjuvant chemotherapy.
0:09:06 I’ve had patients on bone modifying agents,
0:09:08 these are drugs that are supportive drugs
0:09:12 that are typically used in a variety of diseases,
0:09:14 but while there’s benefit, the benefit accrues
0:09:17 over a long period of time, and I’ve pushed those off
0:09:19 because, again, I don’t know that there’s
0:09:21 a right or wrong answer, but in my judgment,
0:09:24 the risk of them stepping out of their house
0:09:27 and coming into the clinic probably doesn’t make sense.
0:09:29 – Most practitioners would probably continue
0:09:31 with the chemotherapy for patients who are young
0:09:34 and otherwise fit and doing well with treatment.
0:09:37 For patients where you’ve had a deep remission,
0:09:40 now one year, two years beyond treatment,
0:09:42 for a lot of those patients, we can probably
0:09:45 safely stop treatment at that time,
0:09:46 and hopefully the patients will continue
0:09:48 to remain in remission.
0:09:49 So it really depends on where the patient is
0:09:52 and what kind of response they’ve had,
0:09:54 but it also depends on the type of cancer they have.
0:09:56 We know that there is a significant amount
0:09:58 of heterogeneity between cancers,
0:10:00 so not all cancers are created equal by any means.
0:10:02 So in each situation, we have to kind of do
0:10:04 the risk-benefit calculus and make sure
0:10:06 that it’s in the best interest of the patient.
0:10:09 – Are questions like this coming up at our tumor boards,
0:10:13 who is the group that you’re able to engage
0:10:16 in real time on such difficult decisions
0:10:18 for individual patients?
0:10:20 – Well, Vinita, as one of my seven Twitter followers
0:10:22 you may have seen…
0:10:26 – I saw that you crowdsourced that, well done.
0:10:30 – Yeah, I crowdsourced the early stage lung cancer question
0:10:31 today.
0:10:34 We have a multi-disciplinary lung tumor board, Vinita,
0:10:36 where these questions have come up.
0:10:39 A lot of curbsiding other docs, that’s been my experience.
0:10:40 I think what’s really interesting
0:10:43 about the problems we’re facing is, you know,
0:10:46 there’s sort of the art and the science of medicine.
0:10:48 And this is really one of those circumstances
0:10:51 that the art of medicine and judgment
0:10:55 and how to apply sort of knowledge about data
0:11:00 to great areas of uncertainty really comes into play.
0:11:02 And it’s been intellectually challenging to do so.
0:11:04 – I’m glad you brought up Twitter because I’m wondering,
0:11:08 is that a viable kind of tool for you guys
0:11:12 for crowdsourcing, for even anecdotal data advice
0:11:14 decision-making in this area?
0:11:17 – I’ve personally found the discussions on Twitter
0:11:21 about this to be really helpful and really informative.
0:11:24 So, to me, yes, you know, you can only give,
0:11:26 you have to be a little bit more general
0:11:29 than you would like to be for PHI reasons, obviously.
0:11:31 But I find it very useful.
0:11:33 – I actually think that Twitter is probably the best source
0:11:34 of medical information right now,
0:11:37 as an academic and an oncologist.
0:11:40 The majority of my data that I’m actually receiving,
0:11:43 I’m receiving in real time from my Twitter feed,
0:11:46 as opposed to waiting for publications to come out.
0:11:48 So it’s actually been very, very helpful
0:11:50 to have access to Twitter.
0:11:52 And it’s just been a tremendous communication tool
0:11:53 from experts around the country
0:11:55 and in the world in general.
0:11:57 We’ve been using our tumor boards
0:11:59 to discuss a lot of these cases
0:12:02 as we alluded to earlier, that the data is very gray.
0:12:04 We really don’t have a lot of information
0:12:06 to base these decisions on.
0:12:07 There have been consensus statements
0:12:10 that have been put out into large publications
0:12:12 from thought leaders across the world.
0:12:15 And we’ve been using those as a framework
0:12:18 by which to make our decisions at Stanford as well.
0:12:21 But to still very much a gray area is important
0:12:23 that we have employees share decision-making
0:12:26 with our patients to make sure that they’re also,
0:12:28 feel that they’re a part of this conversation.
0:12:31 – It strikes me that a lot of the decisions
0:12:32 that you’re talking about making,
0:12:35 you already are at a place of understanding
0:12:37 to a large degree what you’re dealing with,
0:12:39 what kind of cancer, how it tends to behave.
0:12:43 What about the patients that just found a lump
0:12:46 and were coming to you for like the very first step?
0:12:48 How do you, what are the guidelines there?
0:12:52 Like begin, wait it out for two weeks, you know?
0:12:54 – The answer to this in general will really vary
0:12:56 depending on where you are in the country,
0:12:58 what kind of health system you’re in right now
0:12:59 and the where we are in the pandemic as well.
0:13:01 ‘Cause we know that resources are shifting
0:13:06 on a daily basis based on local prevalence rates.
0:13:09 So while I think it’s true that most non-essential
0:13:11 procedures and surgeries are being postponed,
0:13:15 the suspicion for cancer does increase
0:13:18 the prioritization of certain scans or procedures.
0:13:22 So for a newly diagnosed or a new breast mass
0:13:25 that you may feel in the shower, for instance,
0:13:28 that would actually take prioritization to have that worked up.
0:13:32 For men who have an increase in PSA
0:13:34 over a slow period of time,
0:13:37 they probably don’t need a prostate biopsy right away.
0:13:40 So it really will vary on the type of cancer
0:13:42 and the type of patient as well.
0:13:45 But in general, patients with cancer suspicion
0:13:48 will probably be at a higher prioritization
0:13:50 for getting their treatment done.
0:13:54 – So at Flatiron Health, among our practices
0:13:57 which use our electronic health record, ONCO EMR,
0:14:00 we’re able to track patient volume.
0:14:05 And we saw last week a 22% drop in office visits
0:14:09 across the network of practices
0:14:13 that also included a 16% drop in visits
0:14:16 related to chemotherapy all in the past week.
0:14:19 I think those are partially shock of the system.
0:14:21 Let’s reevaluate and see who needs to come in
0:14:23 and who doesn’t, but it was pretty impactful.
0:14:26 I mean, our numbers across our network
0:14:27 are very, very consistent.
0:14:30 And then there was just this big drop last week.
0:14:31 I think a lot of that is just gonna be,
0:14:33 whoa, hold on, we have to figure out what we’re doing.
0:14:35 I don’t think necessarily you’re gonna see
0:14:37 that much drop in chemotherapy,
0:14:39 but I think there’s gonna be a lot of really interesting data
0:14:41 that’s gonna come out of that
0:14:45 to try to understand how this impacted cancer outcomes.
0:14:47 – And to your point, Bobby,
0:14:51 about kind of this being a sort of unprecedented shock
0:14:53 to the oncology care system
0:14:57 for us to really see what kind of an impact happens
0:14:59 on visit volume and treatment volume.
0:15:03 And some of that may even extend to outcomes
0:15:08 and it may be a really sort of fine grain sensitivity analysis
0:15:12 that we sort of have an opportunity to later look back at
0:15:14 and say, well, what really happened
0:15:18 if surgery was delayed by this period of time
0:15:19 and how did outcomes change?
0:15:21 And what really happened if adjuvant therapy
0:15:23 was delayed by this period of time?
0:15:25 How did outcomes change?
0:15:28 I think, I hope that to some extent,
0:15:31 some of that may be a silver lining
0:15:34 in terms of learning from this crisis.
0:15:35 – The other sort of interesting thing
0:15:39 that’s come out of this is it makes you spend a lot of time
0:15:41 thinking how much you really need,
0:15:45 things that you thought you really needed, right?
0:15:49 Like, usually this patient comes in and gets blood drawn
0:15:52 and yeah, I’m gonna do this telemedicine visit
0:15:53 and we’re gonna skip the blood draw
0:15:55 and I find myself saying, don’t worry,
0:15:57 we can do it again in three to six months,
0:15:58 which sort of raises the question,
0:16:01 do they really need that blood draw to begin with?
0:16:04 – Yeah, or that scan or that physical exam.
0:16:07 We’ve all felt sort of the sadness
0:16:11 when we hear a patient describe their five-hour drive
0:16:14 and then their hour-long wait in the waiting room
0:16:16 and then their five-hour drive back
0:16:18 because it’s crazy to try to get a hotel room
0:16:19 on the day of their visit
0:16:22 and this kind of logistical nightmare
0:16:26 that many patients undergo in order to seek cancer care
0:16:30 or seek second opinions or seek clinical trial evaluation
0:16:32 and I think we’ve all wondered, well,
0:16:35 could some of this be happening more efficiently
0:16:37 and in a more patient-centric way
0:16:40 if we were to embrace technology in various ways
0:16:44 and sometimes a crisis is an opportunity for us
0:16:46 to embrace that tech stack
0:16:48 and I think we’re all seeing it happen.
0:16:51 I’ve been sort of floored and amazed
0:16:54 at how much of the Stanford oncology clinics
0:16:58 are now sort of operating in the telemedicine sphere.
0:17:00 I’d love to hear how you guys are managing this.
0:17:03 Which patients are you bringing into clinic?
0:17:05 Which are you managing via telemedicine?
0:17:07 – I mean, I think the whole remote care
0:17:10 telemedicine virtual medicine,
0:17:11 I did my first telemedicine session
0:17:14 and I finished it and my thought was,
0:17:15 where have you been all my life?
0:17:19 – Your patient might have had the same thoughts.
0:17:22 – Yeah, right, like that was easy.
0:17:25 The easy answer is routine follow-up.
0:17:27 So the patients who were coming in for routine follow-ups
0:17:29 who didn’t want to reschedule or push back,
0:17:31 I’ve done those over telemedicine
0:17:33 and that’s been relatively easy
0:17:36 and relatively straightforward.
0:17:38 I’ve also had a couple other patients
0:17:40 who weren’t routine follow-up
0:17:42 but I wanted to try to keep out of the office
0:17:44 thinking about a couple of patients, for example,
0:17:47 with a disease called chronic lymphocytic leukemia
0:17:49 who were on relatively new therapies,
0:17:51 were coming in to get their blood counts checked
0:17:53 so they weren’t just routine follow-ups
0:17:56 but given the changing circumstances,
0:17:59 I felt relatively comfortable doing a telemedicine visit,
0:18:00 making sure they’re okay
0:18:03 and pushing back their lab results for a few weeks
0:18:05 where you obviously can’t do it
0:18:07 is on people who need a treatment.
0:18:11 So people who need medicines to boost up their blood counts
0:18:14 to keep their blood counts from getting too low,
0:18:15 there are ways you can give those at home
0:18:18 but for patients who are getting it in the office,
0:18:21 sometimes it’s just not easy to get that quickly done
0:18:26 and then the regulations around using FaceTime and Skype
0:18:29 and other non-HIPAA compliant platforms
0:18:31 has been lifted at least for the time being.
0:18:33 So I’ve had a couple of circumstances
0:18:36 where I’ve just FaceTimed patients to do this.
0:18:38 – We’ve really dramatically scaled up
0:18:41 the virtual clinics in our clinics in the last two weeks
0:18:42 which is quite ironic
0:18:44 ’cause we’ve actually had virtual capabilities
0:18:45 for over a year now
0:18:48 but it’s literally taking a pandemic to do this.
0:18:49 The utilization of virtual
0:18:52 was around five to 10% of our clinic visits
0:18:53 over the past year
0:18:54 but now in the last week
0:18:56 is now greater than 60% of our visits
0:18:57 are actually now all virtual
0:18:59 which is quite extraordinary.
0:19:04 Yeah, and we have this alignment for the first time actually
0:19:05 where we actually have an alignment
0:19:08 between providers, patients and now even payers
0:19:13 as CMS changed their laws this past week
0:19:15 to allow for reimbursement for televisits
0:19:17 and virtual medicine.
0:19:21 So that’s really changed the landscape completely
0:19:22 and so now we’re seeing a huge rise
0:19:25 in our ability to deliver virtual care.
0:19:27 – So we had a podcast recently
0:19:30 where we talked quite a bit about using virtual medicine
0:19:32 and telemedicine tools for primary care
0:19:36 and sort of triaging symptoms from your home.
0:19:39 Are there particular pressure points
0:19:42 that you’re noticing from the specialist point of view
0:19:44 where things aren’t working so well,
0:19:45 where there are sticking points
0:19:47 or where the data flow gets messed up?
0:19:49 – Part of the thing in oncology
0:19:52 is you administer therapies to patients
0:19:53 and a lot of those therapies
0:19:57 it’s sort of hard to do in a remote setting.
0:20:00 I think from the oncology standpoint, that’s a barrier.
0:20:03 The other area which I’ve sort of seen
0:20:05 and again this has been in a limited experience
0:20:09 is there are often difficult discussions you have
0:20:10 and I think we’re all accustomed
0:20:14 to delivering those difficult discussions in person
0:20:16 and the ability to have physical contact
0:20:20 but I think that’s been a tough part of remote oncology.
0:20:21 – Wow, yeah.
0:20:24 – So much of oncology is an art form as you were saying
0:20:27 and it’s really our ability to connect to a patient
0:20:28 which makes oncology so special
0:20:30 and which is why so many of us went into this field
0:20:31 in the first place.
0:20:34 But it’s very difficult to do that virtually
0:20:36 as much as I would love an emoji.
0:20:38 I think an embrace after giving someone good news
0:20:41 is much more wanted by us
0:20:46 and we also know that the physical exam, as you were saying,
0:20:48 is also very limited for these virtual visits.
0:20:50 We do have some limitations
0:20:52 especially where the physical exam
0:20:53 can be a little bit more important
0:20:56 such as gynecological cancers
0:20:58 like endometrial cancer or cervical cancer.
0:20:59 – What could be better?
0:21:03 Like if you had to brainstorm a feature list
0:21:07 for the platforms that you’ve tried, what would help?
0:21:08 – On our current platform,
0:21:10 we can’t share screens nearly as easily
0:21:14 so I was trying to tell a patient about a lung nodule
0:21:16 and he wanted to see it actually on his CT scan.
0:21:18 So I actually had to take a mirror
0:21:22 and show him his lung scans
0:21:24 through the reflection on the mirror
0:21:26 which I thought was extraordinary in 2020
0:21:28 that we can’t do this quite yet.
0:21:30 – How about the sharing of information
0:21:33 like provider to provider or specialist to specialist?
0:21:34 That’s something that our partner Julie Yu
0:21:36 brought up on the last podcast
0:21:39 as being still not seamless with the data flow
0:21:41 of these telemedicine tools.
0:21:44 – Well, I mean, I’ll give you an example today
0:21:46 that happened to me as one of my patients
0:21:49 who I didn’t think I was gonna need to examine
0:21:51 said, “Oh, I have this thing on my back”
0:21:53 and turned around and tried to show me this thing
0:21:55 on his back and it was,
0:21:57 which as an aside, there have been a lot
0:22:00 of sort of comical technology related things
0:22:02 that have happened in the last week and a half too.
0:22:04 – Like what, like I can’t even,
0:22:06 would you put your phone on your cabinet
0:22:08 and like turn around and take your shirt off?
0:22:10 I can’t even really imagine how that.
0:22:12 – Well, like this was one trying to turn around
0:22:15 and show that my patient trying to show me a picture
0:22:17 of his lower back and calling his wife in
0:22:19 and not being able to see where he was.
0:22:22 Another patient who just wasn’t really used
0:22:24 to using the phone on his camera
0:22:27 and he kept putting his camera up against his ear
0:22:29 so I could see the inside of his ear.
0:22:33 But not that, you assume that everyone
0:22:35 in the world uses technology like you do
0:22:39 and you quickly find out that is not the case.
0:22:43 Like people who aren’t sure what to do with a hyperlink.
0:22:45 So that’s been sort of interesting,
0:22:47 but I’ve had some nice laughs with my patient
0:22:50 around this as well.
0:22:53 – So some of this are sort of growing pains
0:22:56 and rollout pains, but maybe in the future,
0:22:59 if a cancer patient was expecting a certain fraction
0:23:02 of their visits to be over telehealth,
0:23:05 maybe that adoption curve would look different.
0:23:08 – Yes, so I mean, I’ll just give you one example
0:23:09 for a feature that would have been nice.
0:23:10 So this patient who I just told you about
0:23:12 who had this thing on his back,
0:23:14 I couldn’t get a clear enough picture on the video.
0:23:17 He actually took a picture of it with his camera
0:23:18 and then emailed it to me.
0:23:22 I looked at it, I thought I knew what it probably was.
0:23:25 I then went through a long and arduous process
0:23:27 of communicating with his dermatologist
0:23:29 who he was supposed to see next week
0:23:31 and sending him the image.
0:23:32 Boy, wouldn’t it have been nice
0:23:34 if I could have taken the image
0:23:36 right from the telehealth platform,
0:23:39 sent it over to his dermatologist
0:23:42 and messaged his dermatologist on the same platform.
0:23:43 Hey, can you take a look at this
0:23:46 and let me know what you think?
0:23:48 The biggest problem from my perspective to solve,
0:23:50 and this is not just telehealth,
0:23:53 but I think everything is, you know,
0:23:56 real time or fast communication between clinicians,
0:23:59 whether it’s colleagues or second opinions
0:24:01 or docs you refer to.
0:24:04 That’s the biggest pain point for me,
0:24:07 which ultimately could be solved partially with this.
0:24:10 A couple of the observations that I had
0:24:14 watching some of these telehealth visits take place
0:24:18 were just kind of how open and comfortable
0:24:22 a lot of the patients seemed chatting over a video visit.
0:24:25 My sense is that some of that is because applications
0:24:28 like FaceTime and other video chatting applications
0:24:29 are just so much more prevalent today
0:24:32 that a lot of patients don’t feel like
0:24:35 it’s quite as awkward as you might have anticipated.
0:24:39 It was actually interesting to get a glimpse
0:24:42 into how they’re functioning and what they’re doing
0:24:44 and the fact that they’re running in from the kitchen
0:24:46 or, you know, just you kind of get a sense, actually,
0:24:49 of a patient’s mobility and comfort level
0:24:53 with their ADLs, activities of daily living
0:24:54 in a way that you can’t sometimes get
0:24:56 when they’re sitting on an exam table.
0:24:59 So I think it’s been interesting to see
0:25:03 that we might actually learn about patients
0:25:06 in a way that is hard to do when they come to the clinic.
0:25:09 Yeah, you know, it’s funny to say that.
0:25:12 I mean, I’ve found one of the really useful things
0:25:15 is seeing people in their own environments and in their homes.
0:25:18 One thing I always like to do with patients
0:25:22 is I’ll ask them to bring in pictures of themselves
0:25:24 either when they were younger or before they were sick.
0:25:28 And I was telehealthing with one patient
0:25:30 and she was sort of sitting at a desk and behind her,
0:25:34 she had like a million family photos all hanging on the wall.
0:25:36 And I was like, and I didn’t do it,
0:25:38 but I was so tempted to say, hey, could we, you know,
0:25:42 pull a couple of those off and let’s take a look at them.
0:25:45 But you do, you really get insight that you don’t.
0:25:47 And I’ve had like, I literally had two patients,
0:25:49 30 seconds into the conversation, say to me,
0:25:51 oh my God, I forgot to put on makeup.
0:25:54 And, you know, you just realize you see people different
0:25:57 than you see them when they come into the office.
0:25:59 One space that we’ve all heard a lot of discussion
0:26:03 about actually in the context of coronavirus therapies
0:26:06 are clinical trials that are now actively enrolling.
0:26:09 And I think a lot of people have started thinking
0:26:10 about what a clinical trial is
0:26:13 and have heard the word more than they might have before.
0:26:16 But for cancer patients, this is the norm, right?
0:26:18 A lot of our cancer patients are always thinking
0:26:23 about a trial in the future or they might be on a trial now.
0:26:26 We’d love to hear how clinical trial operations
0:26:29 are affected by shelter at home orders
0:26:32 for so many of our non-essential workforce.
0:26:35 How is that playing out for patients on trials
0:26:38 or patients considering trials?
0:26:40 The shelter in place is obviously
0:26:43 hampered enrollment considerably.
0:26:45 We’ve had a tremendous decrease in enrollment
0:26:46 over the last couple of weeks,
0:26:48 which is very understandable.
0:26:50 Patients just don’t want to come to the hospital
0:26:51 nearly as much.
0:26:53 Adding to that is that a lot of trials
0:26:56 are actually holding new recruitment to trials as well.
0:26:59 So a lot of the crew was being held right now.
0:27:00 For patients currently on trial,
0:27:02 they are allowed to continue on treatment
0:27:04 and they are encouraged to do so.
0:27:06 They are allowing for more deviations,
0:27:09 meaning that patients can skip treatments
0:27:11 if they feel that they need to
0:27:13 in order to protect themselves from the virus.
0:27:16 So we’re starting to see that sponsors or trials
0:27:19 are a lot more lenient than they were in the past.
0:27:22 A lot of the trials that are with oral medications
0:27:24 are still being continued
0:27:27 and these sponsors are also feeling a lot more lenient
0:27:29 about shipping drug home
0:27:31 so that patients don’t have to come into the hospital.
0:27:34 I also agree that this is going to cause us to
0:27:37 reconsider the way that we do a lot of our clinical trials.
0:27:39 Is it really necessary that you get
0:27:43 that certain esoteric lab on day 52 of a clinical trial
0:27:45 and make the patient come in for four hours away to do that?
0:27:47 I think this will make us realize
0:27:49 that a lot of the things that we’re doing
0:27:52 are probably not as important as we used to think they are.
0:27:55 – The FDA announced that they’re working
0:27:59 on providing guidance to sponsors and trial sites
0:28:02 to enable sufficient regulatory flexibility
0:28:05 to allow trials to continue through this period
0:28:06 to the extent possible,
0:28:09 while of course keeping patient safety paramount.
0:28:12 What are some of the tactical ways
0:28:15 in which you think this guidance could play out
0:28:18 and in which you think there might be more flexibility
0:28:20 than there was before?
0:28:23 – I think the flexibility ultimately helps.
0:28:26 There is so much concern about not following protocols
0:28:31 exactly to the T and deviations to that.
0:28:34 But I think that flexibility is gonna get people
0:28:37 ultimately more comfortable with having patients on trial
0:28:38 during this time.
0:28:43 To me, it’s certainly it’s understandable
0:28:44 why things are dropping off.
0:28:47 I think it’s also in many ways tragic.
0:28:50 We at baseline don’t put enough patients on clinical trials.
0:28:53 It’s such an urgent need and it’s just disappointing
0:28:56 even if understandable to see why that’s dropping off.
0:28:58 And you probably saw, I think Pfizer made an announcement
0:28:59 that they’re stopping accrual
0:29:01 except for life-threatening conditions.
0:29:03 I don’t know if life-threatening applied
0:29:05 to every cancer trial that they’re doing or not.
0:29:08 For trials where, assuming you have enough staff
0:29:10 to keep taking care of patients,
0:29:13 if you have a trial that doesn’t require visits
0:29:15 outside of the standard of care,
0:29:18 I’d hope we’d be able to see those continue.
0:29:22 One thing that was really personally very exciting to me
0:29:24 is we have a lot, community oncology
0:29:26 does a lot of clinical trials,
0:29:28 something that I think not everyone appreciates.
0:29:32 And we’ve seen a lot of continued accrual to trials.
0:29:34 We work very closely with one particular trial
0:29:37 that we’ve helped do data collection for.
0:29:41 And we’ve seen practices even in the last week
0:29:44 accrue four, five or six patients to this.
0:29:47 Docs, despite adversity, get that clinical trials
0:29:50 are important and are continuing to try to do it,
0:29:51 even in difficult times.
0:29:53 – It’s interesting because, going into this,
0:29:56 I sort of, as an outsider, sort of naively thought
0:30:00 that the broadest level, the advice
0:30:02 or the kind of thinking would be pause
0:30:05 what we can pause safely.
0:30:07 But it actually sounds like what you’re saying
0:30:11 is keep doing everything that we can keep doing safely.
0:30:13 It’s more the spirit.
0:30:15 That’s my perspective, especially,
0:30:17 I mean, it also depends on the trial, right?
0:30:19 So if you’re doing a clinical trial,
0:30:21 which are often the case in cancer,
0:30:24 whether it’s a phase one trial or a phase two trial
0:30:27 for people with bad cancers who have run out of options,
0:30:29 it’s difficult to continue those.
0:30:31 But I think it’s appropriate a lot of the time
0:30:33 to think about how can we make it work.
0:30:37 – We are doing a international cancer registry
0:30:40 right now on patients with coronavirus.
0:30:42 And this was an effort that was largely led
0:30:44 through Twitter, actually, by recruiting other physicians
0:30:47 from other institutions to capture all this data.
0:30:50 And I do think that clinical trial data,
0:30:52 especially randomized clinical trials,
0:30:55 are gonna be more difficult to do in the current era
0:30:57 because of the regulation.
0:30:58 There should be an importance placed
0:31:00 on what we call real world evidence.
0:31:03 And this type of data is gonna be very informative
0:31:05 in the next several months as well,
0:31:06 as we’re gonna get limited data
0:31:08 from randomized clinical trials.
0:31:10 – Let’s sort of go back to where we started
0:31:13 and think about what happens to oncology as a whole
0:31:18 when it’s forced in this moment to go so virtual.
0:31:19 What do you think is gonna stick?
0:31:23 And what do you think we will let fall by the wayside
0:31:26 when we finally get to move out of this moment?
0:31:29 – I do think that virtual clinics are here to stay.
0:31:32 I also think that we’re gonna see a large shift away
0:31:36 from hospital-based care and more towards home-based care.
0:31:39 Do you really need your infusion at Stanford
0:31:41 or at your cancer center,
0:31:44 as opposed to the confines of your living room?
0:31:47 I think if you look at certain examples,
0:31:49 for drugs that we use in lymphoma,
0:31:51 for instance, a drug called Rituximab,
0:31:54 it’s an IV medication that has now been formulated
0:31:56 to be subcutaneous.
0:31:57 And you can imagine a scenario
0:32:01 where you had a digital safety lock on that syringe
0:32:04 that could be activated by your provider
0:32:07 if after a virtual consultation to make sure
0:32:10 that your lab’s look okay and that you were feeling okay.
0:32:12 So I think a lot of the stuff that we’re doing right now
0:32:14 in the clinics can certainly be done at home,
0:32:19 kind of furthering the capabilities of virtual medicine.
0:32:20 – What’s the incentive to keep doing that
0:32:23 after the coronavirus goes truly away?
0:32:25 – Patients in general actually prefer this.
0:32:28 It’s amazing that after these virtual consultations,
0:32:29 I’ll often tell a patient that,
0:32:31 “Well, I’ll see you back in three months,
0:32:32 hopefully here at Stanford.”
0:32:33 And they say, “Well, Doc, actually,
0:32:35 this worked out pretty well.
0:32:37 Why don’t I just see you back on my cell phone
0:32:38 in three months instead?”
0:32:41 I do think that we’re gonna see a greater use
0:32:44 of digital health and public health interventions as well,
0:32:48 and the rise of public-private partnerships.
0:32:50 If you look at the countries that were the most successful
0:32:53 in containing this epidemic,
0:32:55 they’re all countries that employ technology
0:32:58 as a very large part of their response.
0:33:00 You look at South Korea using cell phone data
0:33:04 to be able to contact tracing for patients
0:33:06 who are infected with coronavirus.
0:33:08 Even Russia was using artificial intelligence
0:33:12 and facial recognition to be able to enforce their quarantine,
0:33:14 not suggesting that we do that by any means.
0:33:16 But then you can even look to China
0:33:18 that was using artificial intelligence
0:33:22 to be able to diagnose COVID just from chest x-rays.
0:33:24 So I think that we’re gonna start seeing
0:33:27 a lot more digital health and public health infrastructure,
0:33:30 and I think that’s another thing that’s here to stay as well.
0:33:32 – Specifically around telemedicine,
0:33:33 the genie’s out of the bottle,
0:33:36 and it’s gonna be hard to sort of put it back in.
0:33:38 One of the things that CMS did
0:33:40 that I think was really, really helpful
0:33:41 was expanding the number of codes
0:33:43 that you could use for telemedicine.
0:33:45 I like to think that’s gonna continue
0:33:48 because that just made the whole process
0:33:51 much, much easier for clinicians to do.
0:33:53 I like to think that all of us having
0:33:56 to go through the experience of really asking,
0:34:00 do we really need these things that we always think we need?
0:34:01 Just like sort of value-based care
0:34:03 has pushed us in a direction
0:34:05 to second-guess things that we used to do.
0:34:09 I hope that this does as well.
0:34:10 And then lastly, one of the things
0:34:14 that this whole episode has caused me to reflect on.
0:34:16 I’m fortunately healthy, my family’s healthy,
0:34:19 and I was basically, we were all given news
0:34:21 a couple of weeks ago that you have to stay at home,
0:34:24 you can’t go out, your life’s gonna be disrupted,
0:34:26 and if you get this disease,
0:34:28 there’s like, for me and my age group,
0:34:31 there’s a couple percent chance that I’m gonna die,
0:34:33 and that was really, really hard news
0:34:35 for me to take as an individual.
0:34:37 And in my job as an oncologist,
0:34:39 I give people news 10 times worse than that
0:34:43 every single day, and they deal with it a lot better
0:34:46 than I have dealt with this.
0:34:48 So I like to think that for all of us
0:34:49 who’ve been lucky enough to be healthy,
0:34:51 it gives us a little bit of perspective
0:34:52 of what our patients go through.
0:34:53 That’s wonderful.
0:34:56 The silver lining, in my view,
0:34:58 from sort of a technology perspective,
0:35:02 is that it’s the pressure test of unprecedented scale
0:35:07 for our system to navigate how to incorporate technology
0:35:08 in different aspects of care,
0:35:10 how to keep in touch with patients
0:35:12 when they can’t come into the clinic,
0:35:14 how to make complex decisions
0:35:16 that require coordination in real time
0:35:19 with uncertain data between different specialists,
0:35:21 because this is a time when,
0:35:23 under this type of real pressure,
0:35:24 that’s when these future lists are generated,
0:35:26 and that’s when we realize what we need,
0:35:28 and what we realize we need now.
0:35:30 And so I think that this pressure test
0:35:35 is just going to actually be an incredible learning opportunity
0:35:37 for a variety of sectors of digital health.
0:35:40 The other piece that I think is interesting,
0:35:43 kind of zooming out of oncology in particular,
0:35:45 is just the increased awareness
0:35:46 that’s occurred for diagnostics
0:35:48 and infectious disease therapeutics.
0:35:53 I think it’s given our public, our funding agencies,
0:35:57 companies, investors, everyone across the board,
0:35:58 a deepened level of appreciation
0:36:02 for how important anti-infective agents
0:36:04 and preventive agents really are.
0:36:09 And so I hope we’ll see renewed investment globally
0:36:10 in technology in that domain.
0:36:11 – That’s really inspiring.
0:36:13 Well, thank you so much for all joining us
0:36:15 on the A16Z podcast,
0:36:16 and thank you for everything you’re doing
0:36:18 for your patients every day.
0:36:19 – Thank you so much, guys.
0:36:23 (upbeat music)
0:36:33 [BLANK_AUDIO]
with @vintweeta @pbcancerdoc @sumitshahmd @omnivorousread
Coronavirus is now disrupting the entire health care system, not just because of the burden of dealing with the actual disease itself, but because of everything else that’s had to grind to a halt. One of the areas where we really worry about things coming to a total stop like that is, of course, cancer treatment, which can often feel like a race against the clock even under the best conditions.
In this episode, Dr. Bobby Green, MD (Community Oncologist and Chief Medical Officer, Flatiron Health) and Dr. Sumit Shah (Oncologist and Head of Digital Health, Stanford Cancer Center) join a16z’s Vineeta Agarwala (physician and general partner) and Hanne Tidnam to talk about what is happening to oncology during the outbreak—how treatment is affected; what kind of clinical decisions oncologists and patients are having to make, and how they’re making them; the tech tools that specialists are using, and how they could improve; and what happens to oncology as a whole when it’s forced to go virtual.