publication date: Apr. 24, 2020
Conversation with The Cancer Letter
Tulane Cancer Center chips away at the “digital divide” that keeps the underserved from benefiting from telemedicine
A. Oliver Sartor
Professor of medicine, medical director,
C.E. and Bernadine Laborde Professor of Cancer Research,
Tulane Cancer Center, Tulane University
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.
In the past, few patients had Oliver Sartor’s personal cell phone number.
Since the COVID-19 outbreak in New Orleans, Sartor, professor of medicine and medical director of Tulane Cancer Center, C.E. and Bernadine Laborde Professor of Cancer Research, gives out his number to all patients as part of telehealth visits.
Telehealth can include scheduled calls on the landline or a full workup using electronic medical devices paired with the patient’s laptop. But when standard telehealth approaches fail, the doctor and patient text each other.
“There is a divide by age. There’s a divide in the city and the country with regard particularly to the internet,” Sartor said to The Cancer Letter. “There’s a socioeconomic divide, and to some extent, overlapping with that is probably a racial divide, given that African Americans are more likely to be at a poor socioeconomic strata. There are many African Americans in rural parishes in Louisiana as well.”
“But you know what, you pick up the phone and you call. Everybody has a telephone,” Sartor said.
Tulane Cancer Center has adapted in many ways to COVID-19, from providing testing to asymptomatic patients who receive chemotherapy, to transferring care from in-person visits to televisits when possible.
Now, most patients have Sartor’s cellphone number.
“The thing that has been tremendously helpful is texting, because so many patients can receive a text or an email and a lot of times just reaching out via text or email has been tremendously helpful,” Sartor said. “I have avidly collected cell phone numbers from all patients, and have used texts and email as a relatively routine part of our communication. But, obviously, we tilted that way now. What’s a little bit unusual is that virtually every patient has my cell phone, so that if they need to reach out, they can reach me and we can handle the issue.”
After the pandemic, telehealth will become a more routine part of care for cancer patients, Sartor said.
Of course, “there is certain testing that occurs in a specialized center. We’re able to do genomics that are not typically done elsewhere. We’re able to run very particular scans that are not done elsewhere,” Sartor said. “I think there could be a greater use of telemedicine and a greater comfort with telehealth and telemedicine in this sort of post-COVID world.”
Sartor spoke with Alexandria Carolan, a reporter with The Cancer Letter.
How are things there?
Well, I think the first piece you need to know is that we really have bent the COVID-19 curve, and our numbers of admissions are diminishing. The numbers of deaths are diminishing in New Orleans. The numbers of new cases are diminishing. We really have done a good job with the isolation—and actually, Louisiana has some of the highest per capita testing rates of any state.
We’ve done relatively well, I think, but did not have the density of population that a place like New York City does. New York has been really tough.
And when you say that these numbers have been decreasing in terms of deaths and positive cases, is this in your cancer center or statewide?
This is both statewide and in our cancer center, too.
State-wide COVID-19 statistics are available at the Louisiana Office of Public Health Portal.
Our hospitals are nicely down in terms of admissions. That was a huge concern, initially—were we going to have capacity? The answer is we did have capacity through some rather amazing work at the hospital level, and our cancer center has made very substantial changes. We feel like the worst is over.
We have tested 135,000 people in the state of Louisiana, which per capita, is one of highest testing rates in the country.
That’s good to hear. What does this curve look like in Louisiana?
The curve is bending throughout Louisiana but new cases are appearing now in the more suburban and rural areas.
Nobody has immunity to this thing. I mean, there is no natural immunity, and if you get exposures—inevitably, you’re going to get infected. I think the social distancing has made a huge difference. But not everybody can socially distance with the same effectiveness.
If you live in a prosperous area, having a 4,000 square foot house with two people in it, that’s very different than if you’re six people in a small apartment. Crowding occurs for those people who don’t have the financial resources to create more space at home, there’s more interaction, and many people still must go to work to earn a living.
I’m working at home six days a week. I’m in the office only one day a week, where I’m seeing my cancer patients, but only the prioritized cancer patients.
As you said, some people have the luxury of being able to social distance and some people just can’t. Could you delve into what you’ve seen so far in terms of these disparities? What does that look like in Louisiana?
There is a very significant African American disparity in terms of death rates. It’s not really completely clear, other than age, what the risk factors are. It may be that African Americans are more likely to have multiple co-morbid risk factors, and it not clear whether or not African Americans are seeking care later in the disease cycle.
There’s more obesity in the African American population. There’s more type 2 diabetes. Both of those are factors that contribute to mortality when infected with the virus. One of the things that our teams noted relatively early on is that if you’re obese and end up on a respirator, it’s really, really, really, tough to get you off.
So, if there’s more obesity, then there’s more difficulty getting off of the ventilators, which means there’s a higher risk of death. Diabetes seems to be an issue, whether or not that’s a microvascular disease or something else or may be correlated. With obesity, issues aren’t clear.
But there is clearly an African American predilection for dying from the COVID-19 disease. The other group that has been hardest hit are those with the hematologic malignancies, including the leukemias, lymphomas and multiple myelomas.
These patients are immunocompromised to a greater degree by their diseases. They often have bone marrow dysfunction. They’re often on more immunosuppressive therapies. All those under active cancer management, those with the hematologic malignancies, are unequivocally more likely to have died.
I’m glad you brought that up. We did a story last week about how patients are concerned about their care during coronavirus, because treatment is delayed or canceled. How has Tulane been addressing this?
Well, first of all, we’ve tried to prioritize the patients that need to see us. With things like adjuvant therapy, there is flexibility. Prostate, which is where I focus, the good news is that we have some pretty active hormonal therapies and that we can use our hormonal therapies a little bit longer while waiting for the more definitive radiations to occur.
For surgery, it’s been very problematic—because essentially, all of the surgeries have been canceled. One of the things that we instituted last week, is that we’ve been doing asymptomatic COVID-19 testing on all of our chemotherapy patients.
We’ve got the rapid Abbott 15-minute test, where we can actually do the test on the entry into the clinic.
The good news is, out of our initial three days of testing, I think we’ve tested around 65 or so. We only had one positive among our asymptomatic patients. That patient, by the way, was a hematologic malignancy case. We do have rapid testing available at the cancer center there and hope that can facilitate optimal care.
So, every chemotherapy patient receives testing if they’re asymptomatic?
Yes, but that only started last week.
Every chemotherapy patient is now getting COVID-19 testing prior to the infusion. We started that last week, like I said, it’s just in the preliminary phases, but the good news is we’ve got the 15 minute test. We get a positive result in about five minutes, a negative result in about 15 minutes. We’ve got an analyzer dedicated to the cancer center so we could get those patients tested when they arrive at the cancer center.
And if a patient tests positive, like the one hematologic malignancy patient you mentioned, what are the next steps?
The first thing is they should be notified, of course. It then becomes up to the individual physician to manage it. We don’t have a policy on how a COVID-positive patient that’s asymptomatic ought to be tested if they have cancer, because the individual physician can make decisions regarding how urgent is their therapy, what degree of risk it poses, etc.
For the asymptomatic patient in general, they’re basically instructed to go home and segregate, and then report back if they become symptomatic. By basically putting somebody in self-quarantine, that’s great for managing the virus—but what about the cancer? We did think about trying to put together a cancer center policy for positive patients.
But it really depends on whether or not you’d have an asymptomatic early stage prostate cancer patient who’s under surveillance versus a myeloma patient under active chemotherapy. In general, we would not want to give chemotherapy to a patient with an active viral infection because that would lead to further immunosuppression.
But we are continuing to give chemotherapy. I have patients of mine that are under active immunotherapy or chemotherapy, patients who progressed rapidly after hormonal alternatives, and we really don’t have a choice. I take care of kidney cancer patients who are getting infusions with immunotherapy, because quite frankly, their disease progressed rapidly on the alternative. Even though we’re trying to utilize the alternatives to chemotherapy, when feasible—for some patients, chemotherapy is literally life-saving.
Of course. What changes has Tulane Cancer Center made as a whole in light of COVID-19?
A wide variety of things.
First of all, we’ve really tried to prioritize our in-person patient visits to those people that absolutely need it. We’ve had a tremendous expansion in our telehealth, and they’re using different platforms, either something as simple as FaceTime or a phone call. You can accomplish a great deal on a phone call—or actually having the more formal tablet visit, which is done through our EMR. Prioritizing the follow-up of patients in terms of televisits has been a huge change, and diminishing the number of physical visits to the cancer center has been required under this crisis.
Number two, we’ve created outside utilization of testing so they don’t have to come into the cancer center for their laboratory testing. For our radiation patients, we instituted a patient flow where literally we were starting and are continuing to start radiation at 4:00 a.m. through 8:00 a.m. So that patients can come in and be socially-distanced. Then we restart it at about 4:00 p.m. going to 8:00 p.m. We literally have segregated our radiation patients in an effort to be able to continue their care, but to diminish the interactions that they might have with others.
Then, we, of course, have both questionnaire and temperature checks at the time that any patient comes into the clinic, including all cancer center personnel. All the personnel that comes into the clinic gets a temperature check and a questionnaire for symptoms. If they are symptomatic, then they’re questioned by a physician in order to determine what should be done next.
We’ve had a good volume of symptomatic testing available for some time here in Louisiana, so we can get symptomatic testing done in a variety of settings. But the asymptomatic testing is a change, we put that in the last week for the chemotherapy patients and for the hemo-immunologic malignancy patients as a priority.
That’s an overview—segregating those patients who need to be seen from those who don’t, emphasizing televisits and checks into the clinic, moving the laboratory out as much as possible.
The patients who do need to be seen, we are caring for, and that’s an important message as well. We’re not neglecting to take care of our cancer patients. We’re providing care as best we can under extenuating circumstances.
You said that follow-ups and appointments are replaced with telemedicine when possible. Have you seen a digital divide when it comes to disparities?
I treat telemedicine as going all the way from a telephone call, to those patients going into the more formal EMR. There definitely is an age divide. First of all, because I take care of prostate cancer patients, my average patient is probably about age 70. For many patients in their seventies and eighties, they’re simply not familiar with the technology that would involve a full televisit.
But you know what, you pick up the phone and you call. Everybody has a telephone. The thing that has been tremendously helpful is texting, because so many patients can receive a text or an email and a lot of times just reaching out via text or email has been tremendously helpful.
I haven’t tracked the number of texts that I’ve sent patients, but I’ll simply say that I have avidly collected cell phone numbers from all patients, and have used texts and email as a relatively routine part of our communication. But, obviously, we tilted that way now. What’s a little bit unusual is that virtually every patient has my cell phone, so that if they need to reach out, they can reach me and we can handle the issue.
It’s good to hear that you’re able to stay in touch and lessen the divide in terms of digital difficulties.
There still is some degree of divide. I treat an African American patient who lives in the country, and he doesn’t have a cell phone, doesn’t text, but he has a home phone. That is a little more cumbersome, but nevertheless, we’ve been able to communicate. He’s staying indoors, he’s staying at home, so he’s relatively easy to reach and we’ve communicated two or three times in the last month.
There is a divide by age. There’s a divide in the city and the country with regard particularly to the internet. There’s a socioeconomic divide, and to some extent, overlapping with that is probably a racial divide, given that African Americans are more likely to be at a poor socioeconomic strata. There are many African Americans in rural parishes in Louisiana as well.
Do you have an exact number of how many COVID-19 patients your hospital has seen?
No, I don’t have that exact number. This is one of the problems, patients are getting COVID-19 testing elsewhere. We’re somewhat of a referral center, so patients will come here for their cancer care, but they may get their ordinary care back at home.
One of the things that we’ve found out is that patients have had problems with cough or a fever and they don’t come in to New Orleans, where their cancer care is. They go to their local doctor, who might be 200 miles away. If so, we know for a fact that we’re not getting all the information in from the periphery. We can only comment about the testing done at our center, where we do know. Unfortunately, our hematologic malignancy patients have had a significant number of deaths.
If you have a patient with cancer who is positive in your center, do you treat them for COVID? How does this work?
I don’t consider myself to be a COVID doctor. We refer to the infectious disease specialists who admittedly have been overwhelmed. But nevertheless, generally what we’ve done is follow the CDC guidelines for symptomatic versus asymptomatic.
Mainly, what we’ve been doing is supportive care. They do have some protocols, they do have a corporate protocol. They do have the plasma protocol up and going from previously infected patients, and we have some other protocols as well. So there is a protocol directed therapy, but most of the care is supportive, as you know.
COVID-19 treatment has obviously changed the way cancer care is working right now. Looking past this, how do you think COVID-19 could change how cancer treatment works?
I think that many patients and many physicians will be more comfortable with a telehealth paradigm. There is certain testing that occurs in a specialized center. We’re able to do genomics that are not typically done elsewhere. We’re able to run very particular scans that are not done elsewhere. I think there could be a greater use of telemedicine and a greater comfort with telehealth and telemedicine in this sort of post-COVID world.
That’s a great point. And how are researchers in oncology equipped to respond to COVID-19?
Almost all researchers are familiar with the paradigm of what it takes in order to prove that a drug is effective. Oncologists deal with life threatening illnesses every day. We’re accustomed to clinical trials. We understand clinical trial design, inclusion criteria, and the importance of clinical trials.
I do think that oncologists are uniquely informed through their training and experiences to deal with clinical trials, whereas many other physicians really are not. The idea that you would do a randomized trial is still, for primary care, they’re not used to such matters. I think that we can understand the literature and the necessity for good data. All oncologists are accustomed to dealing with life threatening illnesses, so in some ways, we may be a little less prone to panic than some of the other specialties
At Tulane, is there any research being done related to COVID-19 in cancer patients?
We had, and I’d like to give an attribution to a Swiss colleague who looked at one of the binding proteins for the COVID-19 virus, and that binding protein is called TMPRSS2, which is ordinarily a fairly obscure protein unless you work in prostate cancer research. Here, TMPRSS2 is well known as an androgen responsive gene and it is also, TMPRSS2 is also expressed to the lung.
One of the things we’re doing in the basic labs is to look at the androgen regulation of TMPRSS2 in the lung and to ask questions that may be relevant for viral entry. One of my colleagues has put forth a protocol to look at androgen manipulation of the TMPRSS2, and to determine if there might be an effect on COVID. That colleague is at the University of Minnesota.
The idea came in part from Switzerland, is where I first saw it. The idea that this TMPRSS2 gene, which is known to cancer researchers in the prostate field, can be manipulated by manipulating androgens now may actually be going into a clinical trial.
I’m not able to share the protocol; it’s in the developmental phases and must be viewed in context of other available protocols. You’ll quickly see that TMPRSS2 is an androgen-responsive gene, and so the virus uses it in terms of getting into the cell if it’s part of the viral entry mechanism, which diminishes the expression of TMPRSS2 by manipulation of androgens—it’s certainly a logical way to potentially impact the natural history of the viral disease, but we know little about androgen regulation of TMPRSS2 in the lung, and that needs to be shown.
Is there anything else you’d like to discuss regarding the science of this disease?
I’m a little bit dismayed at the lack of viral research in general. It turns out that infectious disease divisions at many large pharmaceutical companies have been either cut back or abolished altogether. I think the government will need to take a unique place in terms of studying infectious diseases, and how they can influence populations—and how we need to intervene, even though the profitability of such research may be low.
The big pharma companies are, of course, trying to prioritize the research that gets the best return on investment for their shareholders. I think as a nation and as a government, we have to prioritize the viral diseases, even though it is not necessarily profitable.
I think everybody sees the wisdom of that now. There were certain cutbacks at the governmental level that were very unfortunate, that have already occurred, and we’re going to need to be more vigilant in the future.
Is there anything else you’d like to add?
The good news is that critical cancer care has been proceeding, but under different guises—and we’ve made a lot of changes in how we’re delivering that care. Hopefully, the compromise of care is relatively minimal outside of the delays in surgery that, unfortunately, have become inevitable during this crisis.