publication date: Apr. 22, 2020

Conversation with The Cancer Letter

As COVID-19 peaks in San Antonio, Ruben Mesa predicts gradual reopening

Giuseppe Curigliano2

Ruben A. Mesa, MD, FACP

Director,
Mays Cancer Center, home to UT Health San Antonio MD Anderson;
Mays Family Foundation Distinguished University Presidential Chair,
Professor 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.

News coverage of the COVID-19 pandemic in New York has lent urgency to social distancing efforts in San Antonio and South Texas, likely flattening the curve.

“We’re still really a bit in the peak as we speak. I don’t think we’re past the peak, but I think by all estimations we’re hopeful that we have had a flattened curve from the social distancing efforts. The social distancing efforts started in San Antonio and South Texas before they did for Texas as a whole,” Ruben Mesa, director of Mays Cancer Center at UT Health San Antonio MD Anderson Cancer Center, said to The Cancer Letter.

“I’ve shared this with my colleagues in New York, I think we all owe them an indirect debt of gratitude. Not that any of this was intentional, but I think the experience in New York, having been as severe as it was, frightened a lot of the rest of the country into much more genuine compliance than we would’ve had otherwise.

“I don’t think people would have taken the threat nearly as seriously if it had been just the communicated experiences from northern Italy and others. I think those of us in health care who have direct friends over there, clearly were getting the texts and emails and felt that very genuinely.

“But I think individuals just watching the news as to what was happening in Bergamo, it was not nearly as real for them as was the experience in New York. With people in San Antonio, seeing those images and other things, the compliance has been very good. I think that’s in large part because they saw what the stakes were from the terrible experiences in New York.”

Mesa said the reopening of the economy in San Antonio will likely move slowly.

“I certainly understand the economic pressures to try to reopen. Within our region, the city and the county set the tone for that, more than the governor,” Mesa said.

“The city and county have set up a task force with many of the faculty from our university leading that. I think it’ll be a very gradual process. I think what they’re signaling will be very much baby steps. A wider range of businesses open, but in a to-go model a bit like the restaurants are working at right now. A bit of an increase in elective procedures, mandatory masks for all in public. Like in San Antonio, starting tomorrow, there’s a mandatory mask order and a $1,000 fine for violation. So, I think it will be a very, very gradual process.”

 

Mesa spoke with Paul Goldberg, editor and publisher of The Cancer Letter.

 

Paul Goldberg:

Thank you for taking the time to talk with me. How’s it going?

Ruben Mesa:

So far so good. I’ve been very impressed with the efforts of San Antonio, coordinating with the Mays Cancer Center and with the state and the county resources to prepare. Our team has been working very hard to remain solely focused on how we care for our cancer patients and how we try to avoid individuals having worse outcome from their cancer, while trying to keep our patients, our faculty, and our staff safe.

As we try to navigate this process, as other centers have done, we try to keep that front and center in our minds in terms of what are the key things that will help to drive outcomes.

What do we need to preserve in terms of therapy?

So, for example, for radiation therapy we are trying to make it as safe as possible. We clearly, like other centers, have the minimum number of people present in the outpatient environment. And everyone is working from home, except at those times that they are directly involved with patient care.

When we’ve been caring for patients who are receiving radiation therapy, we created a part of the parking lot directly across from radiation therapy, and we have people wait in their cars, and then we send a text them with both the vault number and when to come in.

They come in masked, and we screen everyone at the door, both for symptoms and temperature. They go straight to Vault Three, where they meet their radiation therapist. So, we have a kind of rotating waiting room in the parking lot and in our vaults.

We have a similar approach for infusions. And, again, we’ve tried to optimize infusions. We’ve looked through our schedules for infusions that could be deferred, some uses of Zometa, vitamin infusions, and any of those types of things that could be deferred safely, have been deferred until we’re past the surge. But other things we certainly have kept in mind and kept moving forward.

And all faculty and staff are screened each day, and everyone receives a sticker.

 

PG:

When do the cases peak?

RM:

I think we’re still really a bit in the peak as we speak. I don’t think we’re past the peak, but I think by all estimations we’re hopeful that we have had a flattened curve from the social distancing efforts. The social distancing efforts started in San Antonio and South Texas before they did for Texas as a whole.

And I think that was very helpful. I think to some degree, and I’ve shared this with my colleagues in New York, I think we all owe them an indirect debt of gratitude. Not that any of this was intentional, but I think the experience in New York, having been as severe as it was, frightened a lot of the rest of the country into much more genuine compliance than we would’ve had otherwise.

I don’t think people would have taken the threat nearly as seriously if it had been just the communicated experiences from northern Italy and others. I think those of us in health care who have direct friends over there, clearly were getting the texts and emails and felt that very genuinely.

But I think individuals just watching the news as to what was happening in Bergamo, it was not nearly as real for them as was the experience in New York. With people in San Antonio, seeing those images and other things, the compliance has been very good. I think that’s in large part because they saw what the stakes were from the terrible experiences in New York.

 

PG:

What do you think about the pressure to reopen soon? Are you getting some of that in South Texas?

RM:

I certainly understand the economic pressures to try to reopen. Within our region, the city and the county set the tone for that, more than the governor.

The city and county have set up a task force with many of the faculty from our university leading that. I think it’ll be a very gradual process. I think what they’re signaling will be very much baby steps. A wider range of businesses open, but in a to-go model a bit like the restaurants are working at right now. A bit of an increase in elective procedures, mandatory masks for all in public. Like in San Antonio, starting tomorrow, there’s a mandatory mask order and a $1,000 fine for violation. So, I think it will be a very, very gradual process.

 

PG:

Are you still doing adjuvant care, or have you let that drop off a bit?

RM:

Based on the case burden and the risk in San Antonio, which is clearly lower than it is in areas like New York and Boston, we have still preserved adjuvant therapy for individuals, but we continue to monitor the situation. The San Antonio burden is now just at about a thousand cases, and we’re in a town of about 3 million.

So, we are trying to keep it as safe as possible, but again, trying to really map alternative therapy for those with particularly a curative course, would include adjuvant therapy. If we were in an area with a much higher risk and transmission rate, I certainly wouldn’t fault centers for doing otherwise, but we have tried to preserve that piece.

 

PG:

What about the catchment area? Who is getting hit harder and who is less severely affected?

RM:

I think what we do see is that there’s a higher rate of patients becoming ill who are poor Hispanic patients from our catchment area. I think, as has been seen in the other urban areas where there’s a higher rate of co-morbidities, a higher rate of challenges with social determinants of health.

We believe there’s a higher rate of both ICU admission as well as ventilator use. Now, we’re not totally seeing it to the degree that some of the other urban areas have, but there does seem to be a health disparity piece. We certainly have been very active, as other centers have, in terms of ramping up what eHealth looks like with e-visits.

We’ve been working with community oncologists, trying to guide therapy both with second opinions and other guidance to have people treated as close to home as possible. Our catchment area is quite large.  We have people coming to our practice that live as far as six hours away by car. Our catchment area of South Texas goes all the way down to the Rio Grande Valley and the Texas-Mexico border, where there’s a fair amount of population.

So, we’ve been trying to be a resource through e-visits, and, if need be, even telephone visits to the greatest degree that we can. As well as, most certainly, for probably about 40% to 50% of our visits that can be done remotely, follow-up visits, patients on oral therapies. I deal with a lot of chronic leukemias, a lot of oral therapies—all of those haven’t been moved over to electronic visits.

 

PG:

Are you finding that the digital divide is real? Is it affecting you? How can you move to telehealth when there is a disparity in access to technology?

RM:

It clearly is a barrier. Our institution has re-tasked a variety of individuals to help prepare patients for those visits, including some of our early medical students that are not involved with active care. They have found that many have limitations in terms of access to a computer with a webcam, but many still do have a smartphone, and the ability to do video visits on their smartphones broadens that to a great degree but not 100%.

So, at the current time, just a straight telephone visit also is able to be done at a variety of rates. Currently, Medicare is still deciding as to whether it will cover those. I think they should, as certainly a backup during this time.

The video visits, I think clearly are of better quality: the direct ability to see the patient and to be able to look into their eyes and see how they’re doing and connect. It’s a better connection. But a telephone visit is much better than a canceled visit. So, we really tried to avoid canceling care by using the electronic and phone visits as an additional step and resource.

 

PG:

Which you may or may not be paid for?

RM:

We think we likely will, but the telephone may well be at a discount. Again, we recognize during all of this period, the main goal, as I’ve shared with our staff, is to try to preserve outcomes for our patients–as well as to really diminish their anxiety.

Clearly, this is a terrifying time for all of us, but for cancer patients, I think, doubly so, in that they have all of the stresses everyone else has, including work-related stresses, etc., but then they have cancer, too. So they may be afraid of whether they will get the therapy they need as well as are they at increased risk of something they’ve taken for granted, such as going to the grocery store — even with a mask.

So, I found that, with many of these e-visits with patients, part of the time we really speak about the disease, but part of the time we speak about COVID, how it relates to them specifically and what measures they’re taking.

 

PG:

Are you going to be able to do any studies in this, to learn from it, either on the role of certain types of care that may or may not be needed, or maybe on prevalence, or disparities? Is there any aspect of it that you’ll be able to study?

RM:

We’ve been very interested in trying to learn from this as best we can, particularly realizing that this is not going away anytime soon.

We’re participating in Jeremy Warner’s COVID-19 and Cancer Consortium and are sharing the data that we’re aggregating from the San Antonio area. We’re trying to learn from the consortium as well as compare and contrast our date with that from other centers.

Certainly, our center has been involved with a variety of the therapeutic research. We’re involved with the remdesivir study, and potentially will participate with the ruxolitinib study. I was one of the investigators that was involved with getting ruxolitnib approved for myelofibrosis several years ago, so I am very pleased to see that ruxolitinib may have a role with its anti-inflammatory properties as part of a phase III study.

My colleagues and I through the MPN Research Consortium, which is an NCI-funded PO1, are putting together a trial looking at the potential impact of extra e-visits for monitoring these patients during this time, having conversations with them in a structured way in terms of both safety and trying to alleviate the anxiety during this time.

We are doing that with our nurse practitioners and PAs to try to see if we can have an impact in both diminishing anxiety, but also potential impact in terms of decreasing rates of infection and other things. So, we are trying to learn from this as much as we can.

 

PG:

What impact has it had on your institution in terms of your ability to do what you do–and in terms of the money. Are you getting harmed by this?

RM:

Without question, I think every center is taking a significant financial hit from COVID-19. Our center is well run and well organized, so I think it’s a hit that we will survive, but it clearly will have an impact. 

So, one, is we are under a hiring freeze, and all aspects of growth and things of that nature that were planned, clearly, all of that is deferred for the time being.

It certainly has been tremendously disruptive, as it has, I’m sure, for all, in terms of the clinical research program. We have not stopped our clinical trials program, but we clearly have slowed to primarily enroll patients onto therapeutic clinical trials that we think are crucial in terms of being an option for those patients. But things like observational studies, biobanking studies–all of those are really in a holding pattern during this time.

There’s clearly an impact in terms of the experience that trainees are receiving. There clearly will be an impact that I don’t think we fully have felt yet in terms of the funding environment for research. I sit on the national board of the Leukemia and Lymphoma Society. The LLS like other foundations, are seeing a very sharp drop in philanthropic dollars because, one, much of that philanthropy frequently occurs in the setting of people holding events. But second, with the dramatic challenges in terms of the market. Many people who are involved with philanthropy, clearly, are going to be reluctant to support those things at the same rate that they have in the past. I think we’re going to see an impact on that.

The American Society of Hematology just had a conference call on this on Friday, getting people together, trying to understand what is the impact going to be in terms of on training grants, on junior faculty, in terms of a lot of those key resources they need early on in their careers. I think there will be an echo effect on disrupting some momentum in research that’ll take some real intentional efforts to move forward.

 

PG:

It all sounds like things may be able to start getting back to normal at some point in the foreseeable future. What would that look like for you?

RM:

I think the analogy that Governor Newsom of California used of a dimmer, as opposed to an on/off switch, is probably what we’ll see. I think in medicine as a field, clinical care will bounce back much faster than in some other areas of society because of the clinical need, and I think the appreciation both by government and the public in terms of the importance of health care.

But I think it’ll be gradual. I think we’ll slowly ramp up on what elective procedures. I’ve had a great concern, as I’m sure many others have, in terms of the deferment of cancer screening that has occurred during this process.

We’ve pulled together under our cancer prevention screening committee, a coordinated effort to keep track of everyone who had canceled or deferred colonoscopy, mammography, cervical cancer screening, or potentially lung or others, if they were scheduled for that, so that we can keep track of those folks.

We can contact them when we’re able to bring them in for screenings. Another important part is trying to prevent people from presenting with late- stage cancers, because they missed their cancer screening due to COVID-19.

 

PG:

It’s interesting, because you can look and see the inefficiencies in the American medical system more clearly in the middle of this crisis. Is this something you’re seeing?

RM:

I would say, without question, that we don’t really have a coordinated system. I’ve seen a lot of creativity in terms of trying to make up something on the fly. So, for example, every morning here I participate in a call between the city, the county, the VA, our university and the large medical community in San Antonio.

A lot of the medical training for the U.S. is based in San Antonio, so there’s a daily call that really helps to coordinate between these entities to discuss how many cases we have, the stress on the healthcare system, how many events are in San Antonio, where do we stand with that, ICU beds, etc.

So, that’s a level of coordination that’s really never existed before. But it makes you ask the question: Why have we never thought about these kind of things before in a much more coordinated way?

I speak with my colleagues in London, who were very much ahead of us on the curve with this–the coordination they’ve had at the NHS. They’ve had their own challenges in terms of shortfalls and other things, but their level of coordination is really interesting.

It certainly makes you wonder. We have a very large, well-organized, military system to help us defend against physical threats to the country, but we’ve not really had the equivalent in terms of doing that for a health threat.

So, will something like that evolve? I think it may well be necessary. As I’ve heard our infectious disease doctors speak, they feel that the rate of the mutations of the coronavirus from SARS, the original SARS, to this, potentially is an accelerating process, and that it may be somewhat predictable that another highly contagious variant of this–that is not cross-immune to this one–may come again in another handful of years. How do we evolve our system to be poised to deal with the next epidemic, because the next epidemic is likely, and how do we not repeat the mistakes of the past?

 

PG:

Well, the treatment is going to get better; wouldn’t you think?

RM:

Clearly, clearly. But, of course, if it evolves further, will the new treatments we evolve be as effective. I’m sure you’ve seen the little YouTube video from Bill Gates speaking about the Ebola crisis. One thing I have shared with folks is that I think there are a few things that are indirect positives, without question. I am hopeful our society is going to come out of this and have a much greater appreciation both for what everyone does in health care, but also for the value of biomedical research.

I’m hopeful that it’ll be a time where people’s efforts are really valued and that it’ll open up other opportunities for both COVID- and non-COVID-related research.

 

PG:

Having covered this for months now, it’s impossible to see a response to COVID without a major role for oncology.

RM:

Oh, without a question. I think many of the therapies that have evolved from the cancer world clearly have real relevance here.

 

PG:

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.

RM:

Without a question. The JAK inhibitors, BTK inhibitors, trials with mesenchymal stem cells—obviously that’s a variant of stem cell transplantation– a lot of the anti-infectives that again were developed for dealing with infectious complications of cancer therapy are very closely intertwined, without question.

 

PG:

Is there anything we forgot? Anything you wanted to mention?

RM:

I’ll mention one other thing that we did. We created a separate pathway early on in this in terms of caring for people who were not feeling well. If they’re not feeling well it’s as likely or more likely that they are feeling bad because of their therapy, a different infection, or their cancer than it is likely to be from COVID. And then we really did not want to be sending patients to the emergency room unless if it really was a life-threatening emergency.

So, we created a separate pathway. In a different part of our building, we isolated a unit just to be able to do that sort of analysis with everyone with our people in full PPE. We evaluate patients for their symptoms, screen them for COVID if appropriate, use a separate elevator and be able to work that through a separate team. I think the realities of being able to evaluate potentially infected patients in our environment was something we had to react to on the fly.

We’re trying to learn everything we can from this experience and our new processes to both help patients during this crisis but also moving forward.

 

PG:

Were you able to keep the hospital pretty much COVID-free?

RM:

The way we’re structured, we are in a shared university hospital and there are COVID units. Our cancer patients are on separate units, but it’s not a COVID-free environment. Our cancer center, our outpatient facility, we don’t have the luxury of being able to keep them completely separate. But we do have a workflow for COVID-positive patients to be treated in different spots. And then if they’re receiving radiation, they receive it at the end of the day with a deep clean of the vault when appropriate.

 

PG:

You were able to keep those two worlds separate?

RM:

Correct. And we work to keep those two worlds separate. We’ve also worked to try to have duplicate teams so that if we have individuals who became infected we would have backups particularly with some of the roles that are so sub-specialized, such as our radiation therapists.

I think it’s well away from any large scale opening of venues or events or movie theaters or things of that nature. I think it will be very gradual baby steps. But I certainly hope that it’s not premature.

 

PG:

Well, thank you so much.

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