publication date: Jul. 2, 2020

Conversation with The Cancer Letter

Northwell Health reopens cancer services after COVID-19 deluge

New York health system explores NCI designation in affiliation with Cold Spring Harbor Laboratory

By Paul Goldberg

Alexandria Carolan contributed to this story

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.

Any way you look at it, Northwell Health, New York’s largest health system, took a massive hit from COVID-19.

Northwell has treated over 50,000 COVID patients, admitting over 15,000 of them to its hospitals—more than any such system in the U.S.

The financial hit will end up somewhere between $500 million and $1.6 billion, depending in part on how much the U.S. government will kick in, said Richard Barakat, physician-in-chief and director of cancer at Northwell Health Cancer Institute.

“At our peak, we had over 3,400 COVID patients hospitalized in the Northwell Health system. We were literally the epicenter of the epicenter, with the Queens-Nassau border having one of the highest concentrations of COVID patients in the nation. Two of our hospitals were essentially overrun with COVID patients,” Barakat said to The Cancer Letter. “In response to this massive influx of patients, we went from approximately 4,000 inpatient beds in the healthcare system to 6,000 beds— adding 2,000 beds within the span of two weeks.”

Northwell Health also staffed the temporary hospital at the Javits Convention Center and oversaw the USNS Comfort, the U.S. Navy hospital ship that docked on the West Side of Manhattan.

1-covid-MarcusBanner2-188-cmyk

A mural of health care workers wearing PPE on the Northwell Health headquarters in New Hyde Park, NY.

 

Today, as COVID cases rise in other parts of the U.S., the health system is catching up on the backlog of cancer cases, continuing aggressive recruitment of experts needed for its quest for NCI designation.

“Right when we activated our emergency command center back in February, we ordered over $5 million worth of additional PPE,” Barakat said. “We also already had Group Purchasing Organization with 60,000 square feet of warehouse space supplying equipment to our entire healthcare system. We’re now thinking of expanding that to 400,000 square feet, because we want to be prepared for the future.”

With 16,000 new analytic cancer cases a year, the Northwell Health system is one of the largest in Northeastern U.S. By way of comparison, the Sidney Kimmel Cancer Center at  Jefferson gets about 9,200 new analytic cases per year at its main academic site and a total of around 14,500 throughout its network. Atrium Health, located in the Carolinas, has about 17,000 analytic cancer cases.

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Northwell’s Huntington Hospital housed a COVID-19 drive-thru testing site.

 

This story is part of a series of stories, interviews, and commentaries that track cancer institutions as they seek to reopen, reorganize, and reinvent in the wake of the COVID-19 pandemic:

  • Peter WT Pisters, president of MD Anderson Cancer Center, described his institution’s strategy for handling the pandemic and its aftermath (The Cancer Letter, June 12, 2020).

  • Through the COVID-19 pandemic, half of Mount Sinai’s cancer doctors became COVID doctors, taking care of the sick at the hospital system’s 45 COVID centers, contributing to the standards of managing the disease. On the basic science side, Mount Sinai has developed a serology test and provided its components to NCI, where it was used to standardize and validate a panel of sera for use in evaluating serology devices submitted to the FDA from multiple manufacturers. (The Cancer Letter, May 29, 2020)

  • Programs designed to meet the NCI Community Outreach and Engagement requirements for cancer center designation have positioned the University of Miami Sylvester Comprehensive Cancer Center to monitor the prevalence of SARS-CoV-2 in South Florida (The Cancer Letter, May 22, 2020).

  • Three months after the start of the COVID-19 pandemic, the Seattle Cancer Care Alliance is ramping up plans for a comeback of cancer services (The Cancer LetterMay 15, 2020).

  • Health systems and academic cancer centers are cutting expenses to make up for operational shortfalls resulting from the pandemic—laying off employees, furloughing staff, and cutting salaries and benefits (The Cancer Letter, May 8, 2020).

  • Community oncology practices are experiencing a significant decrease in patient volume, as weekly visits dropped by nearly 40%, while cancellations and no-shows have nearly doubled (The Cancer Letter, May 1, 2020).

Losses from COVID notwithstanding, Northwell Health is moving forward with its plans to create a cancer center that would combine Northwell’s massive clinical operations with basic research at Cold Spring Harbor Laboratory, as well as the Feinstein Institutes for Medical Research, a component of the Northwell Health system.

Since coming to Northwell Health from Memorial Sloan Kettering Cancer Center two years ago, Barakat has been recruiting aggressively, bringing in 32 people to the health system.

“By leveraging the strengths of Cold Spring Harbor, Feinstein, and Northwell, we can do something to really change the way cancer care is delivered to our community,” Barakat said. “This will be a transformative relationship, bringing translational research to the diverse population we serve, while also allowing us to study differences and disparities in this population.

“Bringing all of our resources together—23 hospitals sharing a single medical record; our ability to bring cutting edge cancer clinical trials from Cold Spring Harbor and collect tissue from this diverse set of patients—whether they’re Indian or Iranian, African or Arabic, Hispanic or Chinese, or Russian—and take those tissue and blood samples to Cold Spring Harbor so that we can learn what causes the differences in outcomes and side effects; and through Feinstein, ramped up accruals to NCI, investigator-initiated and industry trials—will collectively allow us to fundamentally transform both how we conduct research and provide clinical care throughout our health system.”

The health system, then called North Shore-Long Island Jewish, and Cold Spring Harbor first announced their affiliation in 2015 (The Cancer Letter, April 3, 2015).

The objective of the union is to seek some form of an NCI designation, though Barakat and his counterpart David Tuveson, director of the Cold Spring Harbor Laboratory Cancer Center, the Roy J. Zuckerberg Professor of Cancer Research, and the chief scientist for the Lustgarten Foundation, say that it’s not clear what sort of a designation would fit best.

“Right now, it’s an affiliation,” Tuveson who is also president-elect of the American Association for Cancer Research, said to The Cancer Letter. “We’ve talked to the NCI about our relationship. They are interested, because we’re not trying to fit into a mold that exists. We have not asked them for resources, either. We haven’t asked for anything other than that they recognize that we’re working together in efforts to go after some of the topics that have been on the table for a while and haven’t been solved: We need much better medicines and we need much better ways to use them, particularly in the diverse populations that Northwell cares for.”

Barakat said Northwell will continue to recruit people who would sharpen its programs and continue to integrate these programs with basic research at Cold Spring Harbor and clinical research through Feinstein.

“I don’t think we want to be pigeonholed into any box. I don’t think New York needs yet another traditional NCI-designated comprehensive cancer center. What we are interested in is something that is unique,” Barakat said. “What we want is something that speaks to what we are trying to achieve. We are really speaking about an alliance of a world-class basic and translational research institute, with the clinical firepower of a dynamic, large integrated healthcare system.”

Technology is making such collaborations between cancer centers easier, and NCI is increasingly willing to accept consortium arrangements. However, the structure considered by Northwell Health and Cold Spring Harbor would be different.

“Most of the mergers that are out there haven’t brought together a true basic science cancer center and a large medical system,” Tuveson said. “None of us are too worried about, in the end, what it’s called. What we’re worried mostly about is that it would be designed in such a fashion that it works well and works differently, benefitting patients and accelerating cancer research.

“We’re putting in our renewal to be a basic science cancer center once again.” However, top-level physicians at Northwell Health have Cold Spring Harbor affiliations and vice versa. Also, a translational medical oncology fellowship at Northwell Health includes postdoctoral training at Cold Spring Harbor.

”They may have one of the largest group of non-Caucasian patients in the U.S., and our affiliation can do something innovative here that you don’t see at any other standalone cancer center,” Tuveson said. The two organizations have focused their research on organoids and are making plans for a phase zero clinical trials program. What we need to do now is finish the experiments. We need to get clinical trials going that are informed by Cold Spring Harbor Laboratory science. We need to get the ethnicity and health disparities programs off the ground.

“The clinical trials apparatus has got to be robust for the early phase trials as well as the advanced trials. And it has to incorporate minority patients. So, these are all in front of us and doable, but will require effort, will require more recruitment.”

Barakat agrees.

“I would characterize it like this: It’s putting our ducks in a row,” he said. “Once we are able to standardize care, create our disease management teams, come up with cancer institute membership criteria, significantly increase our accruals to clinical trials, ramp up our phase I and first-in-human trials, and ultimately prove what our outcomes are, then we will be ready to have the conversation with the NCI.”

Barakat-Richard-fs

Richard R. Barakat, MD

Physician-in-chief,

Director of cancer,

Northwell Health Cancer Institute.

 

 

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

 

A series of photographs by Lee Weissman, a photographer for Northwell Health, accompanies this story.

Paul Goldberg:

We have a lot of ground to cover. Northwell Health was hit hard by COVID. I’d love to be able to get a sense of the impact on the health system, your cancer center, and your plans for NCI designation. First of all, how many COVID patients did you treat? Was that more than anyone in the U.S.?

Richard Barakat:

Yes, to date we have treated more than 50,000 COVID patients, including more than 15,000 inpatients, which is far more than any healthcare system in the country.

Northwell activated its emergency operation center on Feb. 4, which allowed the whole health system to mobilize the resources that were needed. This was before any of the cases began to appear in our region. The first cases in the United States appeared out on the West Coast. New York first started to see cases in early March. And you may recall that New Rochelle, just north of New York City, was an early hotbed for COVID cases.

When it came to Long Island, it came in a storm—like nothing you’ve ever seen. At our peak, we had over 3,400 COVID patients hospitalized in the Northwell Health system. We were literally the epicenter of the epicenter, with the Queens-Nassau border having one of the highest concentrations of COVID patients in the nation. Two of our hospitals were essentially overrun with COVID patients.

In response to this massive influx of patients, we went from approximately 4,000 inpatient beds in the health care system to 6,000 beds—adding 2,000 beds within the span of two weeks. And we began shifting patients, load balancing from one site to another, to ensure that we would not run out of ventilators or beds at any one hospital. As part of this process, we transferred hundreds of patients between hospitals. This effort was made possible by Northwell’s Center for Emergency Services, which is a state-of-the-art, centralized communication and dispatch center that coordinates and directs emergency transport throughout our system.

We also have the largest hospital-based laboratory in the region, and we quickly started in-house COVID testing. Initially, you could only get PCR testing for COVID at the state lab in Albany. However, within a matter of days, we began ramping up our own testing capability, and by the last week of March we had a capacity of over three thousand tests per day.

Within weeks of seeing the first cases, we were inundated with these very, very sick patients. Our JAMA publication was based on over 5,700 patients admitted in a one-month period, with a significant percentage of these patients requiring mechanical ventilation and ICU admission.

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At the peak of COVID-19, Northwell Health transformed the Rust Auditorium at North Shore University Hospital, along with libraries and lobbies, into an ICU unit for the overflow of COVID-19 patients.

 

PG:

Can you estimate the magnitude of a financial hit that the Northwell Health system took?

RB:

Without federal assistance, it’s estimated to be a loss of approximately $500 million to $1.6 billion, out of a $13 billion budget. While these numbers are large, it is important to remember we are the largest private employer in New York, with over 72,000 employees and a $13 billion budget.

Taking into account federal assistance, we are probably looking at a budget gap of $500 million or so by year’s end. Of course, that depends on the final amount of federal assistance that we will receive from FEMA.

 

PG:

What’s the impact of that kind of loss? How do you absorb it? How do you mitigate it?

RB:

A lot of things were put on hold, and all of the clinical activity is going to need to ramp back up—and it’s beginning to.

We’ve learned a lot from this. I don’t think our operations will ever go back to quite the way they were, and we definitely will improve the way we do things.

We’ve realized we can do much more from outside the hospitals and the ambulatory centers, and this has implications in terms of how we provide care and in terms of real estate—not needing as many buildings for staff to work in. We realized that there’s so much that we can do from home, so there’s going to be cost savings with that.

We’ll also become more efficient at what we do. We’ll pivot and use different ways of taking care of patients, such as more extensive use of telemedicine.

Throughout these changes, however, we are absolutely committed to continuing to offer the best care to our cancer patients. We are not wavering from that, and I have the full support of the leadership of the healthcare system in achieving this.

 

PG:

What advice would you give to other cancer centers if they see an increase in COVID patients in their region?

RB:

If I had to give advice to anyone whose COVID cases started to increase, it would be this: You have got to slow traffic through the hospitals and through the ambulatory centers. We did that by canceling all elective visits and pivoting to telehealth. In a one-month period, we went from having 200 clinicians practicing telehealth to over 6,000.

For patients who needed to receive care at our facilities, all wore PPE and went through an assessment that allowed them to be triaged to an appropriate space. We limited visitors and ensured that our staff wore proper PPE and practiced appropriate infection control protocols.

We have a home lab service, called LabFly, which was drawing labs in people’s homes to avoid bringing them into the cancer center. We did home infusions. We did not allow visitors to come in with patients. All of this was done to decrease the flow of traffic.

Very early on, we realized that we needed to decrease the number of elective surgeries. We did, however, continue to perform urgent surgeries. For example, you can’t let someone with a colon cancer that’s about to rupture not undergo surgery.

Throughout this pandemic, our capabilities as a health care system were truly highlighted. You may have seen some of the pieces on 60 Minutes, NBC Nightly News, Bloomberg, and others, with our leader, Michael Dowling, [president and CEO], highlighting the way the staff came together.

We’ve shown how we can respond as a system, and that same response was applied to cancer. At the end, first and foremost in our minds is our commitment to offering the best cancer care for our patients.

3-Rust-Renovation-Complete-66

In Rust Auditorium, the stage, covered projector screen, and marks from where 300 auditorium seats were once bolted remain. Every patient housed there during the peak of COVID-19 was on a ventilator.

 

PG:

Are your plans to build a cancer institute—and seek NCI designation—still on track?

RB:

It’s still moving forward and on track.

What we’re really looking to do is to provide the highest level of cancer care in our community while also performing cutting edge clinical and basic science research. Cold Spring Harbor Laboratory is in our backyard, and the Feinstein Institutes for Medical Research is already part of Northwell Health.

We want to combine the strengths of a world-class NCI-designated basic science cancer research center, the incredible research enterprise at the Feinstein Institutes for Medical Research, and the largest integrated healthcare system in New York, which takes care of an incredibly diverse population of almost two million patients a year, who speak over 120 different languages.

While I think NCI designation is extremely important—and I’m not aware of any cancer center director in the United States who wouldn’t want an NCI designation—what we’re laser-focused on is taking care of our uniquely diverse patient population and improving the outcomes of patients with cancer in our health system.

By leveraging the strengths of Cold Spring Harbor, Feinstein, and Northwell, we can do something to really change the way cancer care is delivered to our community. This will be a transformative relationship, bringing translational research to the diverse population we serve, while also allowing us to study differences and disparities in this population.

Bringing all of our resources together—23 hospitals sharing a single medical record; our ability to bring cutting edge cancer clinical trials from Cold Spring Harbor and collect tissue from this diverse set of patients—whether they’re Indian or Iranian, or Arabic, or Chinese, or Russian—and take those tissue and blood samples to Cold Spring Harbor so that we can learn what causes the differences in outcomes and side effects; and through Feinstein, ramped up accruals to NCI, investigator initiated and industry trials—will collectively allow us to fundamentally transform both how we conduct research and provide clinical care throughout our health system.

I firmly believe that there’s a great deal of value in what we’re doing and that there should be a form of designation, which we’d love to receive from the NCI. Because if we accomplish what we set out to do, I believe that an NCI designation will follow.

 

PG:

How is the reopening going? Are you seeing a rebound, are you seeing patients come back?

RB:

One of the things we did extremely well during the crisis was to develop trackers and databases.

Prior to COVID, we did about 1,000 operations a week, with 20% of those being for cancer. As COVID struck, we tracked every scheduled or planned case in a REDCap database developed under the leadership of Matt Weiss, our deputy physician-in-chief for surgical oncology. We also came up with a scoring system, with 4 being the highest priority and most acute cases, all the way down to 0, which were purely elective cases, and we reviewed every planned case and gave all of them a score.

So, as we began our recovery operations, we had a database tracking over 20,000 planned cases in it. We have now done about 6,000 of these. While we would like to complete all of these cases as soon as possible, there are only so many ORs. To address this, we have increased our OR hours and have started doing elective cases on weekends. It will require more staff, but we will catch up, and because we took a proactive approach to reviewing and triaging, we will handle the most important cases first.

Similarly, where chemotherapy could be safely given less frequently or deferred for a period of time, we did this to prevent unnecessary immunosuppression or exposure to a hospital environment during the height of the COVID crisis. The liquid tumors, the leukemias, the lymphomas—those had to continue to be treated, and we did that, using infection control practices that were put in place specifically to deal with the pandemic.

However, with some of the solid tumors, we had a little bit more flexibility. I’ll give you an example: In ovarian tumors—and I’m a gynecologic oncologist by training and actively practiced for 30 years—you can give Taxol, for example, every three weeks, or you can give it weekly. While the toxicity profile is somewhat different between those two regimens, the efficacy is similar, so we said, “Look, if you can give something safely with equal efficacy every three weeks, do it that way. This way you don’t have the person coming back on a weekly basis.”

We also used a lot more oral agents, and that’s a little easier nowadays, with more availability of targeted therapies.

Even for cancers where surgery is a necessary component of therapy, there are options. In the setting of ovarian cancer, there is a lot of literature showing that you can give chemotherapy first rather than doing these big six-hour debulking operations. So, we pivoted to neoadjuvant therapy whenever possible. We also did this in other diseases, such as pancreatic cancer, giving neoadjuvant chemotherapy rather than doing a Whipple procedure upfront.

That bought us some time, because many of these bigger operations require at least a temporary ICU stay. We knew we had to decrease that traffic in the ICUs, but we never lost sight of the fact that we had to treat our patients. It’s just that we adapted by treating them a little bit differently.

With radiation, we pretty much continued at 85% of our normal volume throughout the crisis, including safely caring for patients with COVID-19, so that didn’t take as bad a hit as some of the other areas.

But all the volume is starting to come back. To help take care of these safely, we are now testing every one of our chemotherapy patients for COVID with nasal swabs before they come in for their infusions. We are also testing all our surgical patients. We try to do this at least 72 hours before their scheduled procedures. And we’re also going to begin to test all our radiation oncology patients.

We also have done—or are trying to do antibody testing—on every one of our 72,000 employees. You may have heard, about 20% of people in New York City tested positive for the antibody. It’s a little bit less on Long Island. But in our employees, we found so far that only about 6% have had evidence of infection. And the antibody positivity rates were even lower in the intensive care units, which shows the power of the PPE equipment that we provided our employees. That is another amazing story about how we managed that.

 

PG:

Which serology test are you using?

RB:

We have actually used tests from five different vendors, and we continue to actively evaluate how they perform both in patients with proven prior COVID infection as well as individuals without known exposure.

 

PG:

So, you have a list of cancer patients whose care had been delayed, and now you’re going through the list and getting them to come back—and that will feed the rebound?

RB:

Correct.

One of the things that market surveys have shown is that patients want to feel safe. And we enhance safety by offering testing, by making sure that both staff and patients are wearing appropriate PPE, by changing the configuration of our clinical areas to allow social distancing, and by multiple other changes, big and small.

And we are getting the word out now that it’s safe to come here.

We are also going to pivot for the future. If COVID resurges, we don’t want to have to scale back operations like this again. To prevent this, we are going to proactively designate some areas as COVID-contained. And we’re especially doing that in the oncology setting, because so many of our patients are immunocompromised. We are not going to say, “Your surgery can’t be done, or you can’t have chemotherapy.” We are creating ambulatory sites which are only for cancer patients, where we universally use PPE, employ viral and antibody testing, and, of course, continually doing the things that everybody should be doing: social distancing, hand-washing, and the like.

And that’s the message we are giving out to patients. And the patients are beginning to feel safer, because they know that we are doing everything we can to prevent them from contracting COVID. One thing we did learn from Wuhan is that cancer patients who contract COVID have a worse outcome, so it’s absolutely paramount that we take care of these patients properly.

 

PG:

Did anything in your life prepare you for this?

RB:

I’ve been in cancer now for 33 years, and I’ve seen a lot. I’ve trained in city hospitals, Kings County in Brooklyn as a medical student, Bellevue in New York City as a resident. I spent 30 years of my life at Memorial Sloan Kettering. You always rely on your life experiences to help you. But, honestly, I don’t think I would’ve ever expected to live through something like this.

It hit me hard, personally. I felt the need to visit my friend, Richard Schwartz, the medical director of Long Island Jewish Hospital, which is one of our tertiary hospitals out here on Long Island, and I walked through every COVID unit with him.

That’s the place that previously had 45 ICU beds and now had over 150 patients on ventilators. These patients were in rooms that I’ve walked through in the past, which previously had nothing to do with being an ICU—sometimes they were not even a clinical space.

As an example, at North Shore University Hospital, within days of the first COVID patient being admitted, every single chair was taken out of the main teaching auditorium, and it was turned into a COVID unit, with almost every single patient in there being on a ventilator. The nurses actually renamed this auditorium as the “MASH” unit.

It was just amazing, this ability to pivot. I mentioned to you earlier, we went from 4,000 beds in the healthcare system, to almost 6,000 beds in less than two weeks—and Northwell also ran the temporary hospital that was built at the Javits Convention Center and was providing oversight of the USNS Comfort, the U.S. Navy ship that was docked on the West Side of Manhattan.

Seeing the patients on the ventilators, with no visitors—that was one of the hardest things.

It’s only starting to dawn on me how emotionally taxing all of this has been on all of us. This is something that none of us ever expected to go through. I am shaken when I hear some of the stories from the ICU staff, the doctors, the nurses; they were talking to family members using FaceTime or Skype, as the only way they could give them a chance to say goodbye to a family member.

Because, remember, we couldn’t allow visitors into the hospital. You can imagine if somebody has a relative with cancer, and then they get COVID, and the only way of saying goodbye is through FaceTime. Those were some of the heartbreaking stories I heard.

But though this unimaginable tragedy, I just can’t tell you how proud I am to be a member of this healthcare system.

Discharge-1---covid-LastMomAmbulatory-11-cmyk

The Alvin & Dorothy Schwartz Ambulatory Surgery Center at North Shore is a separate, safe delivery space for new parents. When the disease peaked, Northwell Health System had over 3,400 hospitalized COVID-19 patients.

 

PG:

Can you talk about clinical insight you’ve gained from this?

RB:

Again, it’s the ability to pivot and adapt. You have to be able to do multiple things at once.

Yes, we have a terrible pandemic, where we’re seeing a significant number of patients going on ventilators. And about 20% ended up needing dialysis as well. These were the sickest of the sick, diabetic, hypertensive with multiple comorbidities. The patients were also frequently from minority populations. This pandemic really hit the African American and Latino community very, very hard.

The coagulation defects were also like nothing we’ve ever seen. These patients get both venous and arterial thromboses. We had patients requiring amputations. This is a multisystem disease that presents in a myriad of ways. There are some patients who are almost asymptomatic or lose smell for a few days, and then you have others that are extremely sick.

What we learned in terms of cancer care was the need to be flexible, to act quickly, to respect what this disease can do. And, again, you must decrease the flow of patients.

We take care of more New Yorkers with cancer than anyone, and we had so many patients because of that. So, we had to be nimble, we had to think on our feet, and we had to think out-of-the-box. Because what we could not do is make them a casualty of COVID.

One of the things which will remain to be determined though—and I don’t know the answer to this—is whether there will be a stage migration, because people were not getting their screening mammograms or their colonoscopies, or because they deferred evaluation of symptoms. I wonder if a year from now we’ll look back and ask, are we seeing higher stage cancers than we should be? Will we see more advanced colon cancers? Will we see more advanced breast cancers? Modeling by the NCI predicts that delays in screening for breast and colorectal cancers will lead to a 1% increase in deaths through 2030, which translates into 10,000 additional deaths from these two cancers. It remains to be seen, but it does concern me.

Another thing we learned is that you have to prepare for an event on this scale. Right when we activated our emergency command center back in February, we ordered over $5 million worth of additional PPE. We also already had Group Purchasing Organization with 60,000 square feet of warehouse space supplying equipment to our entire healthcare system. We’re now thinking of expanding that to 400,000 square feet, because we want to be prepared for the future. But it was the ability of the healthcare system to pivot, to get those supplies, to shift patients from one location to the other. It really took a remarkable, remarkable team effort.

We have now discharged over 11,000 hospitalized COVID patients. I don’t know if you’ve seen this, but Madison Square Garden has put a billboard up which is keeping a running tally of thousands of COVID patients who have been discharged from Northwell hospitals.

I’ll tell you one little interesting anecdote, which warms my heart. I’ve been in the hospitals when it occurs, and it is always a bit of a teary moment—every time a patient is extubated or discharged, a song is played overhead. One of the most popular is “Here Comes the Sun,” from the Beatles.

Many of our hospitals have adopted an extubation/discharge theme, which I think is really, really terrific.

Discharge-2---covid-northern-westchester-10000-cmyk

Staff line the hallways, clapping and cheering, when COVID-19 patients are discharged at Northwell. At the end of the long hallway out of the hospital where this patient was discharged, he was reunited with his family.

 

PG:

How did that come about?

RB:

It started at one hospital, and then expanded organically. With everything they were going through, the staff needed something to cheer about. The hospitals have also had big celebrations, where all the employees gathered with proper PPE, when the 1,000th patient was discharged, when the 10,000th patient was discharged.

We also had pregnant patients. We had one great story of really sick pregnant patient with COVID, who required intubation, but she was ultimately discharged with a healthy baby. Seeing that patient’s discharge, it’s was really hard to practice social distance. You just wanted to jump up and hug the mom.

We had radiology residents redeployed to cover the floors. A lot of the surgeons were redeployed to the intensive care units.

Here in the Cancer Institute, Executive Director Eileen O’Donnell created a project management group that oversaw all the different things that we were doing. That project management group had daily huddles, and everybody was in charge of a different task. We had trackers for how many doctors were out sick, who was in self-isolation due to exposure to COVID, where our staff was redeployed. We tracked how many cancer patients had COVID, and also, unfortunately, patient deaths, because this is information that we will need to inform how best to address the next pandemic.

From a medical oncology operations standpoint, all of our regional site directors had regular huddles with our deputy physician-in-chief for medical oncology, Dr. Wasif Saif, to share information and make sure that all sites were consistently implementing best practices as we learned them. And we shared the best practices we learned not only with ourselves, we also shared this information with the world. During the height of COVID, Dr. Louis Potters, our deputy physician-in-chief for radiation oncology and chairman of radiation medicine, did webinars with hospitals in Vienna and Stockholm, sharing our approach of providing radiation oncology care during the pandemic.

These huddles and other interactions were also not just about how best to take care of patients. It was emotional support, just to reassure people that they could get through this.

As a system, we are also beginning to think how we support our staff through the recovery. For a lot of people, vacation hasn’t been at the forefront. The health system leadership, however, is beginning to encourage our staff to take vacations, even if it is a staycation, to get needed recovery and rejuvenation. Other things that are going to help is a beginning of the return to normal, or at least the new normal. In New York, phase II has started on Long Island, with restaurants, serving outside with social distancing, and other businesses beginning to reopen. Similarly, we expect Manhattan to begin phase II soon.

I feel like there’s a little bit of a light at the end of the tunnel. And I think, whatever we’ve learned from all of this will help us for the future, and will help others throughout the country.

But we couldn’t have done it alone. Hundreds of traveling nurses joined us. Additionally, University of Rochester sent us 14 clinicians, and Intermountain Health, in Utah, sent us 48 of their employees; I can’t tell you how appreciative we are of that.

And that’s the kind of thing that Northwell also does for those in need. During Hurricane Harvey, Northwell sent a whole group of nurses and doctors to help affected hospitals. That’s what healthcare systems have to do: You have to help each other.

 

PG:

Could you tell me about the health disparities you were able to see?

RB:

This illness hit the African American and the Latino community hard. Many of our minority patients throughout our service area were affected. And we know that communities of color, in many cases, are of low income.

We worked with the New York Department of Health to begin offering testing at churches and community centers in Brooklyn, the Bronx, Queens, Staten Island, and Nassau and Westchester counties.

These services are all being provided for free, because we knew that these were communities were hit very hard by this disease, and the only way to get on top of pandemic is with contact-tracing and testing. So, that’s all provided free of charge.

 

 

PG:

Cancer and COVID seem to be related on many levels.

RB:

Yes. We have two big research arms exploring this connection. One of them is the Feinstein Institutes for Medical Research, which is run by Dr. Kevin Tracey. It has five institutes: behavioral science, bioelectronic medicine, outcomes research, molecular medicine, and cancer.

As the COVID crisis took hold, Feinstein mobilized incredibly quickly to start participating in and actually running clinical trials.

Northwell participated in many of the very early trials, including those looking at remdesivir, hydroxychloroquine, and convalescent plasma. Right now, in conjunction with the Feinstein Institutes for Medical Research and Cold Spring Harbor Laboratory, we are looking at a very large trial of famotidine that may demonstrate important effects, both for treatment and perhaps prophylaxis.

 

 

PG:

How does your cancer center differ from other cancer centers in New York?

RB:

As you know, Paul, in the New York metropolitan area, there are many NCI-designated cancer centers. We are not looking to be one of many. We want to do something that’s truly innovative, that’s truly unique, that really brings state-of-the-art research and clinical care to an ethnically diverse and underserved population.

The beauty of what we have created is that we have the ability to bring cutting-edge trials from Cold Spring Harbor Lab to our minority patients in Queens and other parts of our system. We can then collect blood and tissue from those patients as part of these trials to learn about potential differences in biology or response to therapy in these diverse populations.

We’ve got such a wide area: we are in Staten Island, we are in Brooklyn, we are in Westchester, we are in Nassau County, we are in Suffolk County. And we’re building a state-of-the-art ambulatory centers with comprehensive cancer programs in Staten Island, Queens, and Huntington Long Island, because I think it’s unfair to think that the only way that cancer patients can get state-of-the art care is to get in a car and drive to Manhattan. I intend to shatter that myth.

I think we can build something amazing around our regional cancer centers and we can put it in our patients’ backyards. In this model, our patients will be treated by an integrated healthcare system that will not only take care of their cancer, but we’ll take care of their comorbidities, their high blood pressure, their diabetes, their heart disease—whatever their medical condition is.

And they will not have to break the bank paying for expensive parking, several hours of travel or substantial time off to see their oncologists. Our goal is to bring state-of-the-art cancer care right into our patient’s communities, while at the same time giving them the opportunity to participate in cutting edge clinical research.

NCI designation may come from that, but it’s not like I came here and said, “What do we do to get NCI designation?” What I did say was, “What do we do to give these patients who deserve it the best cancer care possible?” Hopefully, NCI will look at that and say, “Wow, what Northwell is doing is truly unique.”

And there’s a growing realization of what this healthcare system is about, and we have incredible people joining us. Dr. Catherine Alfano, formerly the VP of survivorship at the American Cancer Society, has just joined us as director of survivorship. Stacy Sanchez, DNP, from Memorial Sloan Kettering, just joined us as chief nursing officer for the cancer institute. Dr. Joe Herman, who’s going to be our head of cancer clinical trials office, just came from MD Anderson. We have a new chairman of surgery at Huntington, who will be the head of surgical oncology in the Eastern region, Dr. Marty Karpeh (The Cancer Letter, May 29, 2020).

NCI is focused on accruing cancer patients to cancer clinical trials. And you know, Paul, from your work that you’ve done over the years, that there’s a very low number of minority patients getting enrolled into cancer clinical trials. What’s unique about our cancer institute is all of the diverse populations that we care for. We are going to start a translation service, which will translate our cancer clinical trials, and ultimately all of our clinical trials, into multiple different languages so that patients can have study information and consent forms that are in their language.

We are going to pilot this in Queens with our 10 most commonly spoken languages in a practice that we just acquired. The ultimate plan is to set this up as a service that other institutions will be able to utilize as well. These are some of the unique out-of-the box approaches that we are taking.

Our plan, again, is to provide the ultimate in multidisciplinary care, addressing not just cancer, but nutrition, social work, palliative care, and other ancillary services that our patients need.

Because genetics is so important to our current understanding of cancer, we’ve just hired Noah Kauff, formerly the director of cancer genetics at Duke. He is now the head of cancer genetics at Northwell, and we’ve already hired six new cancer genetic counselors so we can provide state of the art genetic risk assessment throughout our entire healthcare system.

We’ve also hired Dr. Jeff Boyd as our chief scientific officer (The Cancer Letter, Feb. 14, 2020). He is now the director of cancer research at the Feinstein Institutes for Medical Research, and also a full professor at Cold Spring Harbor lab.

This relationship between Northwell, Feinstein and Cold Spring Harbor is growing stronger by the day. We have all of our new recruits also interviewed at Feinstein and Cold Spring Harbor. And we have fellows who are spending two dedicated years at Cold Spring Harbor.

So, there’s a real deep integration between the cutting-edge translational research that’s being done and the clinical enterprise that Northwell represents. I think adding all those aspects along with rehabilitation medicine, palliative care, psycho-oncology, that’s what an integrated healthcare system like Northwell can provide.

5-covid-PPE-supplies-3-cmyk

Northwell’s warehouse in Bethpage, Long Island, stores PPE and lifesaving equipment for each of its 19 hospitals.

 

PG:

How far are you from having a conversation with NCI? What don’t you have?

 

RB:

We have excellent clinicians here, but we need to expand on that. We need more expertise in clinical trials. We need more expertise in phase I trials. We need to open up more first-in-human trials, to directly bring agents developed at Cold Spring Harbor into the clinic.

We’ve got to up our game. We have many clinical trials, but we have to do significantly more. And we need to demonstrate to the National Cancer Institute that we can bring these cutting-edge clinical trials to a very diverse group of patients. I think that’s something that’s unique about us, that we see so many cancer patients in so many different communities, with so much to learn from.

I don’t think we want to be pigeonholed into any box. I don’t think New York needs yet another traditional NCI-designated comprehensive cancer center. What we are interested in is something that is unique.

 

PG:

Would the Cold Spring Harbor arrangement be a consortium arrangement?

RB:

I would say no, Paul, because Cold Spring Harbor is a basic science cancer center and does not have a clinical component. I think, what we are talking about is more of a hybrid model, similar to what Wistar Institute and ChristianaCare are proposing, (The Cancer Letter, July 12, 2019).

Again, we don’t care what it’s called. What we want is something that speaks to what we are trying to achieve. And I think we are really speaking about an alliance of a world-class basic and translational research institute, with the clinical firepower of dynamic, large integrated healthcare system.

I think what we’re talking about here is unique and novel and has the potential to benefit a huge number of patients from populations who traditionally have difficulty getting any care, let alone access to state-of-the-art clinical trials.

 

PG:

How far are you from having a conversation with NCI?

RB:

I’ve been here two years, and I’m putting this all together, and I’ll know the answer to that within the next two years.

We’ve recruited 32 people since I’ve been here, and I have many more I want to recruit. I want to build a foundation to create something amazing, and when I’m ready, when I feel that we’ve got it, then we’ll have that conversation with NCI and see what makes the most sense.

But first, I’ve got to put all the building blocks in place. And then when I feel that we’re ready, that we truly affected so many patients, beneficially improved their outcomes, improved the way they are treated, and I feel that we’ve developed an incredible team, we will have that conversation.

I don’t know when that will be exactly. But I think for me, professionally, at this point in my career, I want to be able to show that since I’ve came here, I’ve changed the standards of care, I’ve improved the outcomes of patients. That is why I am here.

To gauge this, we need to monitor how our patients are doing and make sure that they’re doing better, and see how many of our patients are enrolled in cancer clinical trials.

It’s not like you can just get somewhere and then say, “Okay, I’m here now. And I’m ready for NCI designation.” I’ve only been here two years, and I’ve got a lot of things I want to achieve. Once we have put the pieces in place, though, I think that we’re going to give a very, very compelling story.

Importantly, I think this ability to pivot and adapt the way we did, to take care of cancer patients while being the system that was hit the hardest and take took care of the most COVID patients, shows what we can achieve. So, I’m really excited about our future. And I think we’ll get there. And I’m glad that people are learning about Northwell.

 

PG:

Do you think you are on track?

RB:

Yes, I think we are. I would characterize it like this: It’s putting our ducks in a row. Once we are able to standardize care, create our disease management teams, come up with cancer institute membership criteria, significantly increase our accruals to clinical trials, ramp up our phase I and first-in-human trials, and ultimately prove what our outcomes are, then we will be ready to have the conversation with the NCI.

But ultimately you must show that what you’ve implemented has improved the outcomes of patients, including those from diverse and underserved populations.

In summary, these have been two extremely exciting years. It’s really great to have been given this opportunity, and I really can’t thank our leadership enough. Michael Dowling, who’s our incredible CEO, could have recruited anybody. But I am still amazed that a New York kid from Long Island, with the help of an incredible team, has the ability to really change the way that cancer care is delivered, not only on Long Island, but in all of southern New York, and perhaps the country.

 

PG:

I should ask a COVID question as the final question. What have you learned that will make it easier to handle this if or when it comes back in the fall?

RB:

First of all, testing, testing, testing. ASAP. And then continue with utilizing PPE aggressively. I also think COVID-contained zones make sense. We have 23 hospitals, 19 wholly owned. If COVID resurges, we will have to quickly and aggressively recreate COVID-contained zones, if not entire hospitals.

I’ve also had discussions with leadership about keeping some of our COVID-contained sites throughout the summer and fall. And I use the term COVID-contained specifically, as it’s very hard to say “COVID-free,” because this is such a virulent disease.

But to be able to really tell cancer patients that everyone in the cancer centers is tested, and PPE and other measures to reduce the risk of infection are used routinely will go a long way in providing patients confidence that they can get needed cancer care in a safe manner.

We will be prepared for whatever the next chapter brings.

 

PG:

Thank you so much.

Copyright (c) 2020 The Cancer Letter Inc.