publication date: Apr. 10, 2020

Conversation with The Cancer Letter

A view from the plateau: As Italy’s cases drop, oncologists plan post-COVID-19 agenda

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 directory of our coverage is available here.

 

In Italy, the number of people dying from COVID-19 has dropped to about 500 per day—a decrease from the 900 to 1,000 patients who had been dying daily when the disease spread was at its peak.

For Giuseppe 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, this is positive news.

“Less mortality, less people infected, less hospitals overwhelmed by patients. We’ll see if we survive, but it’s something good,” 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).

  • As Italy’s COVID-19 incidence curve flattens, Curigliano sees lessons for the U.S. (The Cancer Letter, April 3).

The curve of COVID-19 patients in Italy has reached “a clear plateau,” Curigliano said.

So, what comes next?

“How to be sure that patients who survived COVID are really negative for the COVID infection,” Curigliano said. “We are going to launch a program in my institution to perform a serological test. On those serological tests, we will test IgG and IgM—the antibodies against the coronavirus—in order to understand who is immunized and who is not.

“Now, we are going to launch a trial with 1,000 people,” Curigliano said. “This is now important, because once the number of infected people goes down, what you have to do is to understand how many people are really immunized.

“We will do also this testing on a population of cancer patients, including five big hospitals in Regione Lombardia. And so the idea is also to study the immunization of cancer patients.”

 

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

 

Alex Carolan:

How have you been?

Giuseppe Curigliano:

We are doing better. We are actually in a plateau, in a clear plateau.

Yesterday we had less than a 500 people dying. Usually the numbers were 900 or 1,000, and yesterday we had just 500. Less mortality, less people infected, less hospitals overwhelmed by patients. We are very happy about this. We’ll see if we survive, but it’s something good.

 

AC:

How are things in your hospital?

GC:

In my hospital, we have also less cases.

 

AC:

Last week you had 10 positive patients with cancer?

GC:

Yes. Now we have just one. In the last week, one new case.

 

AC:

And how are the other patients who were positive?

GC:

Most of them are quarantined, actually. No one died. We have to repeat again the tests in order to understand if they are negative or not. After two weeks, we need to retest the patient.

The curve is going down. The maximum percentage was on March 21.

So, what is the most important topic now? What to do now—how to be sure that patients who survived COVID are really negative for the COVID infection. We are going to launch a program in my institution to perform a serological test. On those serological tests, we will test IgG and IgM—the antibodies against the coronavirus—in order to understand who is immunized and who is not. This is quite important. And we have to do this for both health professionals and for doctors.

 

AC:

Whom will the program be testing? Will it be testing everybody who tested positive?

GC:

My idea is to design, specifically, a prospective trial in which we test all doctors and health professionals that have been positive for sure—or all doctors, patients, and health professionals who had symptoms and had never been tested. Because, you know, many had symptoms, but they were not tested, because there was no deterioration of the clinical status. And then, of course, also testing people who look healthy to understand if they have contact with the virus. Because you can be completely asymptomatic.

 

AC:

Right. How many people are we talking about here?

GC:

Now, we are going to launch a trial with 1,000 people.

 

AC:

And what is the timeline for this trial?

GC:

We submitted to the ethical committee last Friday, and we hope to have the approval by this Friday. So we will start next week with the trial.

 

AC:

There’s been a lot of talk about antibody testing in the U.S. as well.

GC:

Yes. This is now important, because once the number of infected people goes down, what you have to do is to understand how many people are really immunized.

 

AC:

And what is the scientific question that this trial is asking?

GC:

The scientific question is how many people are immunized for coronavirus. The second question is looking at positive doctors or patients—what is the time when you need to be immunized with the serum conversion from IgM to IgG?

Our study is just to understand who is immunized. I mean, you test IgG and IgM in the patient, but you do not collect the plasma of those patients. But those are exactly the same patients that can donate the plasma, and to use their plasma to treat other patients.

 

AC:

Is there anything else our readers should know about this?

GC:

What we will do, of course—we will do also this testing on a population of cancer patients, including five big hospitals in Regione Lombardia. And so, the idea is also to study the immunization of cancer patients. So, this is not only for health professionals, but also for patients.

 

AC:

Now that the curve has finally plateaued—and I know this may still be far out—when do you expect to resume follow-up visits and routine visits for your patients?

GC:

Now, it’s too early to start again the follow-up. We prefer to have zero infected people—like in China. And we hope to reach this number—zero—we hope at the end of May. Then, every activity will restart. The first priority will be, of course, to give opportunity to high-risk patients to come back for visits and follow-up. And then we will do a graduated recall for all the patients according to priority of visit.

 

AC:

Does that mean that’s when the whole country will likely stop being on lockdown?

GC:

The idea of the government is to start removing the lockdown for some specific areas of the country, and for some specific people. Everything will be normal first for younger people who have been immunized. For elderly populations, maybe it’s too early, so we have to protect them.

There would be a national program in order to remove the lockdown. And this would be a gradual program that will consider, of course, the general testing of the serum. Who is immunized, or not? And, of course, also the specific population of our country—leaving at the end the elderly population that has been most affected by the virus infection.

 

AC:

Let’s talk about telehealth. How does your hospital plan to move forward with this?

GC:

Oh, this is a very good question. We had that discussion just this morning. So, our idea is to use much more telehealth. You know, you don’t need to see a patient who has no symptoms, who did a lot of tests at home and they are negative. You can do a visit with telehealth. You can even weigh the patient and all the needs of the patient without coming directly to the hospital.

For monitoring safety of specific drugs, you can do the same. I believe that following this coronavirus infection, we will use much more telehealth and we will use it much more for patients for whom you don’t need to come to the hospital.

 

AC:

So, you expect there to be fewer in-person visits?

GC:

At least for asymptomatic patients for follow-up visits.

 

AC:

This sounds like good news going forward, yes?

GC:

The patients are very happy. We did a lot of visits with telehealth. They can see you in the computer exactly like you are seeing me. It’s the same. It’s like being in person. The only thing that they are missing, maybe, is the human touch—because you will not visit them. But they know very well that if they have an abnormal finding, they will talk to you. And so, a patients that can come to the hospital will be the only ones that have abnormal findings, clinically or on tests.

 

AC:

In the U.S., there are hospitals that have considered establishing COVID-19-negative hubs similar to yours during coronavirus. How did your hospital make this decision? Was it difficult to go about this?

GC:

No, because once the epidemic started, the first decision of the national health system was how to protect patients who are not COVID infected, and have other type of problems. So patients who need an orthopedic surgeon for fracture, patients who need cardiovascular intervention for cardiac asthenia, or other acute cardiac events, and finally—cancer patients.

The first decision was to have COVID hospitals, just COVID hospitals—and then hubs in order to accept patients with other disease that are COVID negative. Cardiovascular hubs, orthopedic hubs, and finally, cancer hubs.

 

AC:

Was this a quick process?

GC:

It was decided in one day. Yes.

They communicated: In Milano, you have three hubs, that are the National Cancer Institute, European Institute of Oncology, and the Humanitas Cancer Center. So, in your hospital you will do checkpoints. Only COVID-negative patients will come. And all the cancer patients of the other hospitals will be sent to you for surgery, chemotherapy, and radiation oncology.

 

AC:

Do you think COVID-19-negative hospitals are feasible in the United States?

GC:

In our experience, we are a COVID-free hospital since two and a half months ago. And this, you know very well, we had less than 20 patients positive overall—less than 20.

 

AC:

Right, and now you’re down to one.

GC:

So, in an endemic area where you have, in Regione Lombardia, 50,000 positive patients—we had less than 20. And in terms of health professionals, the health professionals that are positive in our hospital are less than 15. It works. This is an example. It’s a very clean hospital with specific pathways. We did a lot of triage, and so you really protect the health professional and patients.

 

AC;

It sounds like an excellent model for others to follow if they’re able to. On the topic of taking care of health professionals, your hospital was certainly successful doing so. Was this because of access to PPE?

GC:

When I arrive in the hospital every morning, also for doctors, they take your body temperature and then they will give you a mask once a day like this and some gloves for the whole day. Every morning, every one of us will have a mask and gloves. For health professional involved in basic procedures, like bronchoscopy or direct contact, they have much more advanced personal protective equipment. It’s very important to protect the health professionals.

 

AC:

Of course. And is there any advice you have for health care professionals in the United States?

GC:

For my colleagues who are medical oncologists, my suggestion is really to create hubs in cancer centers for patients who are COVID-negative, and who should be treated according to the priority that they decide.

It’s really important to have personal protective equipment, because the more you are protected, the more you can protect your patients. This is my message for my colleagues.

 

AC:

Before we end our conversation, is there anything else you’d like to add?

GC:

For now, in my country, in order to restart, the first endpoint is to understand who is immunized or not. The next step will be to generate something like an immunological fingerprint or ID card—let’s say immunological ID card—that can tell you that you are immunized, and so you can go back to work, and you don’t have any risk for the patients you will take care of.

 

AC:

That sounds like a good next step. Well, thank you again for taking the time to speak with me.

Copyright (c) 2020 The Cancer Letter Inc.