publication date: Apr. 3, 2020
Conversation with The Cancer Letter
A COVID-19 update from New York:
“The only thing I hear at night now is the wail of ambulances”
Benjamin Neel, MD, PhD
Director, Laura and Isaac Perlmutter Cancer Center;
Professor, Department of Medicine, New York University Grossman School of Medicine
This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is available here.
It’s a jump that’s hard to fathom:
Two weeks ago, there were 600 detected COVID-19 cases in the state of New York. At this writing, there are over 100,000 confirmed cases, a 170-fold increase that has filled hospitals and depleted medical supplies at an unprecedented scale.
“I don’t think anybody who’s alive has experienced anything like this at all, unless they’ve possibly been in a war zone. Even then, this is a very unusual war zone,” said Benjamin Neel, director of the Laura and Isaac Perlmutter Cancer Center and a professor in the Department of Medicine at the New York University Grossman School of Medicine.
“Certainly, I haven’t experienced anything like this,” Neel said to The Cancer Letter. “I think it’s pretty clear that this is the largest public health emergency, easily, in this century—probably the biggest since the avian flu epidemic in 1918—and maybe the largest public health emergency in the history of the country.”
According to 2016 data from the American Hospital Association, 6.1% of New Yorkers are uninsured, and there are 2.66 beds per 1,000 New Yorkers.
Over half of the 100,000 cases statewide were detected in Manhattan and the four neighboring boroughs, making New York City the latest epicenter of the COVID-19 outbreak—nearly 1,600 have died at this writing. City data show that the 2,449 intensive care unit beds are nearly at capacity, even as health officials expect more patients to show up.
At the NYU Langone Health system, a surge of patients sickened by SARS-Cov-2 has filled its hospitals, forcing the reopening of Tisch Hospital—one of the older hospitals that has been partly closed.
“Our hospital is pretty close to its normal capacity in beds. The hospital has been transformed into a largely COVID hospital,” Neel said. “Also, we’ve used other facilities that are adjoined to our superblock to expand our capacity.
“I hear that we still have another seven to 10 to 14 days—I’m not really an expert on that estimate—but we have more time to go and more patients will be coming in. I’m confident that [the curve is] not flattening that much.”
Patients with cancer, too are showing up with evidence of COVID-19.
“We’ve seen patients come in for presentation with a likely abdominal neoplasm, and they have ground glass lesions on their lungs that are now sort of recognized immediately as COVID, and they’re asymptomatic,” Neel said.
Updated data from Italy show that about 16.5% of people who die from COVID-19 are patients with cancer, based on a sample of 909 patients. The vast majority of patients in the study sample have one or more comorbid conditions. An earlier review of the fatality estimates is available here (The Cancer Letter, March 20, 2020).
On-site physician encounters for medical oncology at NYU are down by more than 50% as the Perlmutter Cancer Center moves its operations online.
“We’ve really pretty much changed our practice paradigm. Many visits are being done remotely. Initially, they were by phone visit, but right now, largely by telemedicine,” Neel said. “We find that roughly 75% of our patients can do that. Almost everybody has access to the types of technology that you need to do it.
“We’ve instituted very increasingly stringent screening protocols for patients coming into our outpatient centers across our network, which spans Brooklyn, Queens, Manhattan, Staten Island, even, and Long Island. We’ve excluded visitors, with very few exceptions, from the cancer center.
“Everybody gets their temperature taken at the door. We have a very robust screening questionnaire. So, everything is completely changed. Clinical research is significantly impacted, obviously.”
Cancer specialists are being reassigned to inpatient services as NYU hospitals fill with COVID-19 patients.
“We currently have two heme-onc attendings on the inpatient service and serving as medicine attendings. Three of our fellows, two of them at NYU and one at Bellevue, our affiliate, have stepped up,” Neel said. “I know that similar situations are occurring at our satellite campuses at NYU-Winthrop and NYU-Brooklyn.”
In a March 21 news briefing, New York Governor Andrew Cuomo announced that 40% to 80% of the state’s population is likely to be infected by the novel coronavirus. This translates into about 7.8 million to 15.6 million New Yorkers.
“Younger people listen up: 55% of NYS #Coronavirus cases are ages 18-49,” Cuomo wrote in a March 21 tweet. “Young people aren’t invincible. You can get this and you can give it to someone older you love. You shouldn’t endanger your own health & you certainly shouldn’t endanger other people’s health. #StayAtHome”
The stay-at-home orders were, unfortunately, “a little late,” because of a delayed national response, Neel said.
“I think, obviously, we lost a month of time,” Neel said. “‘We’ being the United States—not New York City—lost at least a month of time in not being adequately prepared with having enough testing and enough materials and supplies for this current situation. So, that’s the thing that would have helped. And again, probably acting earlier to impose social distancing and things like that.
“But it’s sort of like a double whammy—if you don’t have enough testing to rapidly trace contacts and isolate them and enforce that, then you get rapid spread and that’s what happened. But again, I don’t think this is a situation that anybody in their experience, at the government level, expected either.
“It would have been better if people grasped that in advance, but once people saw what we were looking towards, people take it very seriously. Manhattan is pretty busy. I live on a busy street, but the only thing I hear at night now is the wail of ambulances.”
Neel spoke with Matthew Ong, associate editor of The Cancer Letter.
The eyes of the world are on New York City at the moment. Have you experienced anything like this in your career as a physician?
Well, I don’t think anybody who’s alive has experienced anything like this at all, unless they’ve possibly been in a war zone. Even then, this is a very unusual war zone. Certainly, I haven’t experienced anything like this.
I think it’s pretty clear that this is the largest public health emergency, easily, in this century—probably the biggest since the avian flu epidemic in 1918—and maybe the largest public health emergency in the history of the country. So, I think that none of us have experienced anything like this.
Can you describe what you’re seeing on a daily basis? What changes have been made at your health system and in your cancer center?
I don’t see patients, so I actually haven’t been at the cancer center since two weeks ago. I actually was home, because I thought I had a mild sore throat and some congestion, and I wanted to make sure I wasn’t getting it, so I stayed home for seven days and right before the end of the seventh day, I, being not used to being at home during the day, so I was walking really fast, like I walk outside, and I definitely broke my toe, and maybe a bone in my foot.
So, I’m just working completely from home for pretty much 18-hour days. It’s amazing how much you can get done remotely. I think that’s going to be one of the changes that the health system realizes as a consequence of this emergency.
Well, first of all, I should say that the physicians and nurses and staff at NYU Langone and the leadership have just been incredibly impressive in terms of their response to this crisis. The hospital has been transformed into a largely COVID hospital, and the hospital management has done a really remarkable job of adapting to really very dramatically changing conditions on an almost minute-to-minute basis.
My colleagues, particularly those on front line, patient-facing physicians that are seeing this—the emergency room docs, the respiratory docs, the intensivists—they’ve really done amazing work. I think that’s probably true across the whole city and the metro area.
At the cancer center, I think that our physicians also have really stepped up and some of them have actually been redeployed to inpatient services. We currently have two heme-onc attendings on the inpatient service and serving as medicine attendings. Three of our fellows, two of them at NYU and one at Bellevue, our affiliate, have stepped up. I know that similar situations are occurring at our satellite campuses at NYU-Winthrop and NYU-Brooklyn.
But then, in the cancer center itself, we’ve really pretty much changed our practice paradigm. Many visits are being done remotely. Initially, they were by phone visit, but right now, largely by telemedicine. We find that roughly 75% of our patients can do that. Almost everybody has access to the types of technology that you need to do it.
Almost all new visits are being done by telemedicine, with patients evaluated as for how emergent the visit would be, and arrange for labs and scans and other tests to be done first. Then, on the day that they come in, they would see their physician before they start therapy. We’ve also decreased routine revisits.
People are coming in for regular therapy. Our infusion volume is down somewhat, but it’s not in any way down the way our “in person” physician-encounter visits are down. Patients are basically having usually telemedicine visits the night before to make sure everything’s okay, and then, they come to the cancer center and get their infusion. Or sometimes, it’ll be coordinated so that they come to the cancer center and are seen by their physician before they get their therapy.
We’ve instituted very increasingly stringent screening protocols for patients coming into our outpatient centers across our network, which spans Brooklyn, Queens, Manhattan, Staten Island, even, and Long Island. We’ve excluded visitors, with very few exceptions, from the cancer center.
Everybody gets their temperature taken at the door. We have a very robust screening questionnaire. So, everything is completely changed. Clinical research is significantly impacted, obviously. Several of our providers, nurses and staff have contracted the disease. Fortunately, everyone is doing well. Many of them are back at work.
At this rate, how many New Yorkers are expected to contract the coronavirus, based on projections so far?
There are various assessments about what fraction of the population in New York is going to get this virus. It’s pretty high. The numbers have a large variance. I think the governor [Andrew Cuomo] even said up to 80% at one point. I think there’s going to be variation in those numbers. Clearly, a lot of people.
Do those estimates account for undetected cases, etc.?
I think, actually, that number probably does. I don’t think he’s saying that 80% would be symptomatic, because if 80% were symptomatic, 100% would be infected. I think he’s actually taking the higher number. I think you’ve raised an interesting point though, is that when the public listens to these various estimates, they may not be hearing the same estimate, or the estimate may not be based on the same facts.
There is a significant number of asymptomatic patients, and, of course, that’s been a real challenge. Probably the most important factor in driving this pandemic to where it is, is the asymptomatic transmission.
I don’t even remember—I guess it’s been maybe three weeks since the last time things even began to approach normal around here—our planning began in late January, early February. But I don’t think that anybody could have anticipated the scale and scope of the problem.
I am in no way a water carrier for administration above me—I don’t always agree with every decision they make—but that notwithstanding, I think they’ve done a really good job. I think they’ve inspired a lot of confidence for everybody who’s working here. So, we’re just trying to do our part at the cancer center.
Have beds that are designated for the cancer center been converted for inpatient emergency purposes?
We don’t have a freestanding cancer center with separate beds, so, that’s not an issue. In Manhattan, we have a large outpatient cancer center on 34th Street and the satellite overflow cancer center on 38th Street. Cancer doesn’t really stop, so we still have a very large number of patients who are getting treated, and we continue to see patients. There’s no plan to close any of our cancer infusion centers or outpatient centers. They’re all open. That goes for all of our sites across the network. Obviously, they’ve all seen a drop in volume.
Much of that is intentional on our part, because we want to make sure that our patients and our staff are safe, to the extent possible. Particularly our patient population, which is highly enriched for immunosuppressed or frail, patients with comorbidities—the kind that are exactly the ones who do extremely poorly with this disease—but our cancer practices are open everywhere. We do have an inpatient floor for bone marrow transplant and for the heme-onc service, and the number of inpatients is markedly less than it normally would be. All elective bone marrow transplants or semi-elective bone marrow transplants, of course, have been suspended.
Note, and again, this is, in many ways, largely motivated by the fact that we don’t want to expose our patients to risk in traveling here and possibly encountering other COVID patients in the immediate aftermath, but also obviously for resource preservation.
We still have a small inpatient service. It’s smaller than it normally would be, and we always do our best to keep people out of the hospital. I used to say when I was an intern and a resident that the hospital is a horrible place to be, unless you need to be there. I think that’s still true. We try to keep our patients out of the hospital normally, but we’re doing everything we possibly can to make sure that our patients get the best care outside the hospital, and have the least transit to any of our centers as possible.
Again, I literally have not left my apartment for two weeks, except to go downstairs one day to pick up a package. There was a lot of grumbling among city residents in the first couple of days, but I think, in fairness, most New Yorkers have taken this quite seriously since we shut down.
Unfortunately, it was a little late. It would have been better if people grasped that in advance, but once people saw what we were looking towards, people take it very seriously. Manhattan is pretty busy. I live on a busy street, but the only thing I hear at night now is the wail of ambulances.
What do you think happened here? Yes, New York City is the most populous and the most densely populated city in the U.S., but what strategies would have helped slow the spread in the U.S. if put in place earlier? What are your thoughts?
Well, I think, obviously, we lost a month of time. “We” being the United States—not New York City—lost at least a month of time in not being adequately prepared with having enough testing and enough materials and supplies for this current situation. So, that’s the thing that would have helped. And again, probably acting earlier to impose social distancing and things like that.
But it’s sort of like a double whammy—if you don’t have enough testing to rapidly trace contacts and isolate them and enforce that, then you get rapid spread and that’s what happened. But again, I don’t think this is a situation that anybody in their experience, at the government level, expected either.
We’ve all seen many stories about hospitals in New York running out of beds and health care workers running out of supplies and PPE, and dead bodies being stored in refrigerated trucks—a scene eerily similar to what we’ve seen in Wuhan and Lombardy. Have you heard from your health system on these issues, and are you facing any of these challenges as well?
Well, our hospital is pretty close to its normal capacity in beds. First of all, our main hospital is new. It’s only been open for a year and a half. Again, I don’t mean to make this sound like an advertisement, but I think that the way our management designed the hospital, actually, put us in a much easier position, because every room was designed to be converted to a negative pressure room. So, that helped a lot in terms of converting things to ICUs, and things like that, very quickly. So, that helped.
We also had our old hospital, Tisch, that was partly closed, and there were plans being made for how it was going to be renovated and used to expand our capacity in the future. Tisch, which until two years ago, was our main hospital, has now been reopened and redeployed for taking care of excess patients.
Also, we’ve used other facilities that are adjoined to our superblock to expand our capacity. So, we are still taking patients and giving them outstanding care.
But I hear that we still have another seven to 10 to 14 days, I’m not really an expert on that estimate, but we have more time to go and more patients will be coming in. I’m not directly involved in those discussions. There are lots of other contingencies being looked at to try to deal with these patients. I don’t speak for NYU Langone overall, but I know NYU Langone’s philosophy, and we put patients first. We’ve always been a patient-centered institution, and we continue to be patient-centered through this pandemic.
What are your staff hearing from your cancer patients, existing or new? And are they seeing cases among your patients who have cancer?
We have had a few cases of cancer patients with COVID disease. I know from talking to my colleagues that they’ve had some patients who’ve had COVID disease. What we often see is unanticipated COVID disease. There was a case the other day that was a patient in the surgical service who was asymptomatic, but had telltale signs on their chest imaging.
I will say one thing: there hasn’t been a lot good to come out of this epidemic, but one of the things that’s helped our place is it’s actually really motivated more use of multidisciplinary tumor boards, and things like that, to make decisions about care.
So, if you don’t have, basically, unlimited surgical capacity anymore, because you need to conserve resources and space for COVID patients, a lot of issues that would have been decided without multidisciplinary input, now are getting decided in multidisciplinary tumor boards, which is great for us. It’s been something that the cancer center has been trying to promote for a long time.
But we’ve seen patients come in for presentation with a likely abdominal neoplasm, and they have ground glass lesions on their lungs that are now sort of recognized immediately as COVID, and they’re asymptomatic. Or they have a story that they had a cough two weeks ago and now they’re fine. So, yeah, we’re seeing that happen sometimes.
We’re seeing people come to the door with a fever that ordinarily we would just work up, but they’re usually viewed as presumptive COVID and sent home if they’re stable, or to the emergency room if they’re not. So, yes, this does not spare cancer patients, doesn’t spare cancer doctors, doesn’t spare cancer nurses. It doesn’t spare staff at cancer centers.
You spoke briefly about telehealth earlier—has NYU Langone had a robust program for a while now? And have you overcome so many of the other challenges that I’ve heard about from other health systems who are developing telehealth programs?
It was just relatively recently that we’ve been moving towards having a telemedicine capacity, but necessity is the mother of invention. When it became clear, about a month or six weeks ago, or maybe even longer, that this was going to be a problem in terms of potential strain on our outpatient facilities, management really was able to move quickly and get it established across the network, especially for cancer services.
As I said, there is very heavy utilization of telemedicine now by our medical oncologists. That’s been able to be improved over what was being done in the initial weeks, which was just phone visits where possible. On-site physician encounters for medical oncology are down by more than 50%, and they’ve largely been supplanted by telemedicine visits with a few phone visits in between.
Right, you were talking about early preparation for the pandemic in January.
I hate to talk about advantage in a situation like this where no one has any “advantage,” but we had the disadvantage of suffering from Sandy, and I wasn’t here then, but I know from my colleagues the stories of how that happened.
I think that this administration at NYU was the same people who were able to bring us through the Sandy experience. They’re very experienced in crisis management, so I think they got a very early start. The hospital executives got a very early start in really trying to think through all aspects of the upcoming problem.
Those planning sessions began in late January, for sure. On the research side even, we were getting communications about having contingency plans. I have oversight of seven floors in the research building too, and I have sitting on my computer a contingency plan for every lab.
I have everybody’s contact information.
There are hierarchies of notification inside every lab. All this stuff was planned considerably before the laboratory-based research was curtailed so much.
How are you handling basic research as well as clinical trials?
All the laboratories in the cancer center that are in my space are supposed to be reporting their temperatures for every individual in their lab, morning and night. The other thing that’s been remarkable is to find out how many people don’t have a thermometer.
Thermometer availability at the pharmacies was one of the first casualties of COVID. You can’t get a thermometer anywhere in New York, I don’t think. But they report in, every day, because I want to keep track of our cancer center researchers.
So far, I think we’ve only had one rotation student in one lab who has COVID. He’s not a clinician. Some of our clinicians who have labs, they got COVID, but they didn’t get it in the research cancer center. They got it in the outside world.
It might be too early, but are there signs that the rate of detected new cases in New York is slowly flattening as a result of containment measures, i.e. social distancing policies? What are you seeing in the reports coming out so far?
Well, it’s a little early to tell. We’ve had a couple of false glimmers of hope. In the first couple of days last week, the cases were doubling every three days. Then there was a report that they were doubling every 4.7 days and there was a little glimmer of hope.
I must say I didn’t look at yesterday’s statistics, because we have a meeting every day. We don’t really have a formal command center at the cancer center, but we have a formal clinical/research-integrated-across-the-network executive session every day from 5 p.m. on, and I think the world record for ending was 8:45 p.m. I can’t thank these people enough for what they are doing for the center and for patients.
The first week when we had this, we had them on the weekend, too.
We met every day from 5 p.m. to 7 or 7:30 p.m. Then, after that, we felt it’s really important to try to maintain as much communication and transparency with the physicians and staff as possible.
And, I must note, in these meetings how great all the network partners have been, as well as the clinical leaders in medical oncology, radiation oncology and surgical oncology.
My wife doesn’t make dinner anymore, because it was getting burned all the time. So, I go and I write these newsletters every night, one for the physicians and APPs, and one for the staff. That usually doesn’t get done until 10, 10:30 p.m. And then, usually, I have some other work to do. And I’m up again at 5.
I think I did hear that there was some indication that there might be some flattening. But others are saying peak COVID is seven to 10 days away. So, I haven’t had a chance to critically evaluate that, but I’m confident that it’s not flattening that much.
It’s early days, again, but if there’s anything that we can learn, what have we learned so far from our handling of this pandemic?
That’s a political question that I don’t want to address in my capacity. I have very strong political views about the central government’s response to this, but I will not be able to give you those in the context of my position.
Got it. Did we miss anything?
This I will say, as sort of a semi-political comment. I think the health care industry, the pharmaceutical industry, everybody who’s involved in health care in the United States, gets a lot of criticism. Increasing amounts of criticism. But I don’t hear a lot of people in the public criticizing doctors, nurses, and front-line personnel.
Actually, everybody’s hoping that the pharmaceutical and biotech industry can get a vaccine, or get some good drugs for this disease. So, I think that’s been a lesson that a lot of people haven’t commented on too much. But I’ve certainly noticed it.
Every day at 7 p.m.—well, I don’t often hear it, because there’s not as many apartment buildings around here, or maybe it’s just because most of the people up here have left or they’re doctors and are not home yet—but every day at 7 p.m., when we’re on this call, somebody’s got their window open, and we hear people come out and shout for the doctors and first responders. There’s a cheer every day. Every night at 7 p.m., they do that.
I see the Empire State Building out my bedroom window, and it was lit up for medical responders and first responders. I think that the response of the people taking care of these patients has been truly heroic, and that’s a word that I don’t use a lot, because I think it’s grossly overused. But in this case, it’s totally true.
Those intensivists and those emergency ward docs, they’re overwhelmed. We have multiple intensive care units now that weren’t there three weeks ago, and they’re all being staffed. I would say, almost without exception, at our center, physicians, nurses, and other advanced practice personnel have realized that that’s why we’re in this business, and we have to do whatever it takes.
On the cancer center side, I think that it’s very important that we do whatever we can to maintain the cancer services while this is going on, because cancer doesn’t stop just because there’s a virus raging through the community. So, I think we’re doing a good job of doing that. I think our patients are getting treated well.
So far, I think that nobody’s going to have an adverse outcome for their cancer from this pandemic. That’s our main goal. And that’s why we’re working to constantly adapt, because viruses generally take advantage of their hosts by adapting, and we need to do the same.