publication date: Apr. 3, 2020

Conversation with The Cancer Letter

As Italy’s COVID-19 incidence curve flattens, Curigliano sees lessons for the U.S.

Giuseppe Curigliano2

Giuseppe Curigliano, MD, PhD

Associate professor of medical oncology, University of Milano;

Head, Division of Early Drug Development, European Institute of Oncology, Italy

 

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.

Social isolation and containment have begun to flatten the curve of COVID-19 cases in Italy, Giuseppe Curigliano said to The Cancer Letter.

If the country stays under lockdown until at least the second weekend of April, the curve will go down, said Curigliano, associate professor of medical oncology at University of Milano, and head of the Division of Early Drug Development at the European Institute of Oncology .

“I am very optimistic now, because, you see, it’s really a flat curve here. The number of new cases is decreasing, and it’s quite clear we’re going to achieve something better,” Curigliano said.

We’ve been reaching out to Curigliano regularly:

  • What to expect: Oncology’s response to coronavirus in Italy (The Cancer Letter, March 11).

  • Curigliano: “I don’t want to see more people dying” (The Cancer Letter, March 20).

  • Curigliano: Italy’s COVID-19 cases keep rising; maybe next week the curve will flatten (The Cancer Letter, March 27).

Italy’s Prime Minister Giuseppe Conte mandated a complete lockdown of the country in early March. The U.S. federal government has yet to order a nationwide lockdown. Rather, states are responding to the threat as they see fit.

While New York has the highest number of cases of COVID-19 today, Florida and Texas are among the states that are expected to see a rapid spike in newly detected cases in the near future.

Does Curigliano see the curve flattening in the United States at the same rate as Italy?

“You are rising. On the horizon, I don’t see this curve flattening,” Curigliano said. “You are 50 states—any state with a specific local governor will decide what to do and what not to do. I believe you will have 50 curves that will be completely different in the country—at different times.”

The solution is social isolation and total lockdown, Curigliano said.

“There is a solution to the spread, and this has been demonstrated in China. It is going to be demonstrated in Italy. The only solutions are not drugs or clinical studies. The only solutions are social isolation and containment—containment in the areas where you have a lot of people infected,” Curigliano said.

 

Curigliano spoke with Alexandria Carolan, a reporter with The Cancer Letter.

Alex will continue to check in.

 

Alex Carolan:

How is your family?

Giuseppe Curigliano:

My family and my wife is fine, also. We survived.

 

AC:

That’s great. How are your patients doing? Do you have more patients with COVID-19 than when we spoke last week?

GC:

We have more patients. This morning, we received another patient, who is a young patient with early breast cancer that is triple negative. She was receiving adjuvant chemotherapy for early breast cancer. She was hospitalized for pneumonitis.

 

AC:

Has she tested positive for coronavirus?

GC:

Yes. She has tested positive.

 

AC:

How many patients total now does your hospital have?

GC:

My hospital actually has something like 10 patients positive.

 

AC:

I think last week at this time it was eight; right?

GC:

Yes. We have two more patients.

 

AC:

Are these patients who are entering the hospital with no symptoms, and then they show symptoms after?

GC:

Yes, usually when they start treatment they have no symptoms of COVID-19 infection. Just after starting chemotherapy, they developed COVID-19.

 

AC:

Right. So, after chemotherapy, basically, they show symptoms of COVID-19, and then you treat them for it?

GC:

Yes, correct.

 

AC:

A couple weeks ago you mentioned you had a patient with lung cancer who had pneumonitis and symptoms of COVID. How are they doing?

GC:

Yes. He recovered. He was dismissed by the hospital on Monday morning. He survived it. Now, we should wait at least one week, and then he will do the test again. If negative, he will come back to the hospital to receive treatment again.

 

AC:

Have you seen any patients who have developed COVID-19 after recovering from the disease?

GC:

No, until now, no. I know that some patients have been described, but not in my experience.

 

AC:

That’s good to hear. I’d like to start where we usually do—what the numbers look like in Italy. How many cases of COVID-19 are there?

GC:

We have 115,242 patients. It’s a huge number—and the patients who died are 13,915. It’s a really huge number. I just heard from some friends from Spain, and they arrived at 10,348 deaths in three weeks. So, it’s really dramatic.

 

AC;

Are the numbers still going up the same amount?

GC:

No, no—actually, we are going to reach a plateau. If you look here, we are in the plateau. We are going to flatten the curve. Now it’s more clear.

Italy screenshot

  

AC:

When do you expect to see the number of cases go down?

GC:

So, if we maintain the lockdown until Easter, I am quite sure that for middle April it will go down. I am very optimistic now, because, you see, it’s really a flat curve here. The number of new cases is decreasing, and it’s quite clear we’re going to achieve something better.

 

AC:

You previously mentioned that cancer patients who test positive for COVID-19 have about a 20% mortality rate. Is this still the case?

GC:

We had an update—actually, the number for cancer patients is 16.5%, so, less than 20%. Most of the cases are non-small cell lung cancer, head and neck cancer, and patients who are smokers and with hypertension.

 

AC:

Where are these numbers from?

GC:

The Istituto Superiore di Sanità, the National Institute of Health [in Italy].

 

AC:

In terms of treatment for COVID-19, The Cancer Letter published an article on a class of drugs used for immunotherapy—interleukin-6 receptor antagonists—that could potentially treat symptoms of COVID-19. How does this work?

GC:

I heard all the details of this trial. This is a realized trial with tocilizumab. Tocilizumab is an anti IL-6 drug that is used for management of graft versus host reaction in transplanted patients. There is a trial ongoing. We don’t have data to tell you if it is working or not. But in any case, the trial completed the accrual and the data will be analyzed.

 

AC:

Right.

GC:

Then, we have other trials ongoing in Italy. The trials ongoing are with the antiretroviral therapy that actually is used for treatment of HIV—those are anti-HIV drugs. Then, we also have a trial ongoing with chloroquine and azithromycin. It is exactly the same trial ongoing in France—an antimalarial drug plus an antibiotic drug.

 

AC:

What is the scientific question these trials are designed to answer?

GC:

The primary aim is to treat patients with pneumonitis that is related to an increase of IL-6, a massive cytokine storm related to the activation of the immune system against the virus. The hypothesis is, if you use a drug against IL-6, you reduce the cytokine storm, and you have an improvement of pneumonitis.

 

AC:

Since we last spoke, I’m sure you’ve seen that the United States is now number one in terms of coronavirus cases in the world.

GC:

As we anticipated.

 

AC:

Yes. You saw this coming a few weeks ago, because it seemed like our situation was going to get worse than Italy’s—and it currently is. What do you think went wrong?

GC:

You know, I believe that the president of the United States decided not to start with social isolation and containment as soon as possible, despite Professor Anthony Fauci, the primary advisor for the president, suggesting that he do this. There is a disconnect between the political decision and scientific advice—because you have the best advisor in the world to control this infection and the COVID-19 spread.

Despite this, political decisions are not going in the right direction. The problem, as it was in Italy, is the balance between the economy and the potential economic crisis related to the spread—and scientific advice. That was very clear, also, in the United States.

This is the reason why you have spreading, dramatic spreading of the virus. I believe you should do a clear communication with The Cancer Letter. There is a solution to the spread, and this has been demonstrated in China. It is going to be demonstrated in Italy. The only solutions are not drugs or clinical studies. The only solutions are social isolation and containment—containment in the areas where you have a lot of people infected.

The first thing is to contain the state of New York, because it’s dramatic, the situation in New York. I know from many friends that are working in clinical practice that there is shortage of personal protective equipment, there is shortage of ventilators, and they are starting to do triage for patients. Who should we propose for intensive care units? They need to select the patients. There is a selection according, of course, to performance status, to age, comorbidities. They will not have the opportunity to access the intensive care unit for all the patients.

 

AC:

Is this happening already? This triaging of patients based on comorbidities?

GC:

Yes, in the United States, I know because I read the tweets of all the medical doctors. They are starting to select patients, absolutely—and also in The New York Times.

 

AC:

The lack of personal protective equipment is a really big problem. The government also hasn’t enforced social isolation to the same extent as Italy. Based on that, do you see the curve flattening in the U.S. at any point soon?

GC:

No. You are rising. On the horizon, I don’t see this curve flattening. You are 50 states—any state with a specific local governor will decide what to do and what not to do. I believe you will have 50 curves that will be completely different in the country—at different times.

The problem now is New York City, I believe. You need to invest a lot there, because millions of people are living there. I expect that many people are also dying and you don’t know that they are COVID-19 positive. This is the reason.

I read that a young woman arrived in the hospital in the U.S. with no insurance—so she did not have access to an intensive care unit, and she died. In my country, we have a nationalized health system, and we reduced everything. We have clear numbers. We know how many people are dying, because we are transparent.

I don’t know if you will register all the people who will die in the United States. Anthony Fauci predicted from 100,000 to 200,000 people that will die, and also President Trump says this. It’s important, now, to offer care to all the people that need care, including people with no type of access to insurance. It’s very important.

 

AC:

It is very concerning. Is there anything else you’d like to add?

GC:

As a reporter, it is important to raise the big problem of personal protective equipment. As you know, also in Italy, we have many doctors who are positive. As I said previously, close to 10,000 health professionals actually are positive in Italy.

It’s important in the United States to avoid this. If you have many doctors who are positive, they will spread the virus in the hospital and outside the hospital. The second point is to stress this concept of social isolation and containment. Now is the time to save lives—and then the economy will start again. You are a big country, and it will start again.

We had also a problem with personal protective equipment, so the situation was quite similar to the ones you are living now in the United States. Actually, there are 10,007 health care professionals infected in Italy. Seventy one doctors have died.

 

AC:

And these were primarily family doctors; right?

GC:

They are half nurses and half family doctors. Yes.

 

AC:

Thank you so much for speaking with me today. It’s hopeful to hear that the curve is flattening in Italy.

GC:

Now in Spain, the situation is so severe. In Spain, in three weeks, they had 10,348 dead. Consider that our numbers now are actually from two months of spread. In Spain, in three weeks, they had as many cases in two weeks that we had in three months. It’s dramatic.

 

AC:

It’s very upsetting. Thank you again for taking the time to speak with me.

GC:

Stay safe. Thank you, be careful.

 

AC:

Yes, you as well. I’ll check in next week.

Copyright (c) 2020 The Cancer Letter Inc.