publication date: Jul. 31, 2020
Conversation with The Cancer Letter
Stephen Nimer: Cancer patients are coming in for treatment, Florida’s COVID-19 spike notwithstanding
Stephen D. Nimer, MD
Sylvester Comprehensive Cancer Center
The Oscar de la Renta Professor of Cancer Research
This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage is available here.
“Our chemotherapy and radiation therapy volumes have been very robust. Probably because of the NCI designation, we are seeing significantly more patients than last year,” Stephen D. Nimer, director of Sylvester Comprehensive Cancer Center, said to The Cancer Letter. “Compared to last year, we seem to be up about 15%. We’ve been growing by about 8% to 9% for quite some years. This year is even more.”
Sylvester received the NCI Cancer Center designation last July (The Cancer Letter, July 29, 2019)
Located in Miami-Dade County, Sylvester is in the hottest of hot spots of the pandemic. At this writing, Florida has had 461,371 cases of COVID-19, with 71,511 cases diagnosed in the past seven days—more than any state in the U.S. The number of deaths is at 6,586.
“Finally, this past week our numbers have started to come down. But throughout the pandemic we have stressed that if you come to see us, you’re not going to get COVID from someone in the hospital,” Nimer said. “As you know, Sylvester has an in-patient cancer only facility that has 40 beds, which we use primarily for stem cell transplant patients, CAR T-cell patients and leukemia patients. We don’t have any COVID patients in our Sylvester facility, and we have continued to conduct stem cell transplants and give chemotherapy and radiation therapy safely.
“Then, we have the university hospital, which has around 400 beds, including hundreds of beds available for cancer patients,” Nimer said. “We have several floors of the university hospital that are strictly devoted to COVID patients. The COVID floors are on top. It’s an isolated area; people aren’t traveling through it. We keep the COVID-19-positive patients and PUIs in separate surroundings from the rest of our patients the moment they arrive in the Emergency Department.”
Nimer said he worries about long-term effects of the pandemic.
“Our concern is that people are going to show up with more advanced cancers, with metastatic disease or incurable disease. Like the rest of the country, we stopped doing screening mammographies and colonoscopies for a while. Those were thought to be elective procedures; right?”
Nimer spoke with Paul Goldberg, editor and publisher of The Cancer Letter.
How are you holding up?
We are quite busy. Our chemotherapy and radiation therapy volumes have been very robust. Probably because of the NCI designation, we are seeing significantly more patients than last year.
In addition, I think that, based on the organizational structures we put in place for our pursuit of NCI designation, our health system and our university have been relying on the infrastructure, expertise and outstanding people within Sylvester to help develop a robust internal testing facility and program to help us deal with COVID-19.
As loyal and caring members of the University of Miami, we’ve been honored to help out.
Our nurse leaders have helped set up testing facilities and run our testing hotline, while our physicians have written guidelines for our patients and employees.
Our researchers have provided expertise, instruments and reagents, so we could quickly ramp up PCR testing capacity. We have also helped address key public health issues, like identifying and isolating close contacts to reduce viral transmission.
To do this, we have worked extremely closely with executive leadership and with student health, employee health, athletics and with many departments across the university, especially the Department of Pathology, with whom we meet daily, to make sure our testing practices are appropriately validated, including our serologic testing platforms for seroprevalence studies.
Why is Florida the hottest of the hotspots? What do you think went wrong?
I think we had a false sense of security.
I talk to my cancer researcher friends in New York all the time. Shortly after things got really bad in New York City, we peaked at about 49 COVID positive in-patients. So, we figured that maybe we had dodged the bullet; and everyone was saying we aren’t seeing so many cases…, “Oh, it’s the warm weather,” “It’s the UV light, because everyone’s out in the sun.” But those things didn’t turn out to be true.
We also heard that, like the flu, when it gets warmer in Florida, the virus will disappear. And that wasn’t true, either.
I guess we attribute our cases to the obvious retrospective conclusion that like many, many other states, we probably opened up too early.
You know, I would love to see data about the role that opening restaurants played in spreading the virus, because when I drove around getting takeout, I saw lots of people in restaurants that were not part of the same family—lots of young people sitting together and eating dinner. Of course, not wearing masks while they were eating and talking and drinking.
I also think that the timing was against us. Based on what was happening in the Northeast, we were cooped up for months, with stay-at-home orders, etc.
Then, when the Northeast got better, people were feeling a little bit more confident, so they “let us out.” They opened up the beaches here, and people started getting together, because that’s what people do. And there were lots of conflicting directives about wearing masks, so many people hung out without masks.
There are a lot of young people in Miami; it’s a young city. And I think that that had a great deal to do with it. But I also think there are several factors that maybe haven’t gotten enough attention.
First, Florida has a huge elderly population. About 20% of the 21 million people who live in Florida are 65 or older.
I believe the current numbers show that roughly 48% of the COVID-19 deaths in Florida have occurred among people who were in assisted living facilities.
While there was a several-week period where we were seeing a lot of younger people, once again, the COVID-19 patients we are seeing and hospitalizing are pretty sick—and they are elderly.
The second factor is that Florida, like California, has a huge agriculture industry, including the citrus industry, tomato industry, and others. These industries are dependent on migrant workers who often live in very close quarters, are transported to and from work together, and may be working shoulder-to-shoulder.
COVID infections in these workers has led to big increases in the numbers throughout Florida, not just South Florida, and probably in California, too.
What can you say about disparities? At Sylvester, you probably have the best view of disparities anywhere in the world.
We’re seeing the same thing as everyone else is seeing.
Supermarket workers, bus drivers—many of these “essential jobs,” where people can’t work from home, are more often held by minorities. And, of course, like everybody else, we’re still seeing that the people who are dying have significant comorbid conditions that are more commonly seen in minority populations.
Florida is a big state, with a lot of people, and we are disappointed that people don’t wear masks the way they should.
There is good news, though; over the past week, the numbers now are going down. The number of COVID-positive patients in our hospital is going down. The number of COVID tests we are doing per day is going down. The percent of COVID tests that are positive is also going down.
It seems like we may be over a peak, but even after the earlier peak, the downside of the peak wasn’t very steeply down. So, this time, even if we’re no longer at the peak, we don’t know how long we will stay at this level, or something near this level.
Different models are showing different predictions.
It could be a plateau rather than a peak?
And then there’s no guarantee that there will not be another peak.
When kids go back to school, people have been predicting another bump up.
But we don’t know what that may look like. I do think people are scared. Seeing just how many cases are occurring in our county or our state.
We get a lot of winter visitors from the Northeast, and everyone said, “Well, there are subways in New York, and everyone is so jammed together.”
We don’t have subways. We aren’t all jammed together down here—but there’s been a lot of illness in Florida, plus a lot of asymptomatic infections.
How have your surveillance efforts been going? You were doing serology testing through the outreach (The Cancer Letter, May 22, 2020) Has that resumed?
We did some serologic testing early on, but more recently we have been largely focused on PCR-based testing. As you imply, we have done a couple of seroprevalence studies. Interestingly, we did a serologic study of our healthcare workers.
We generated an IRB-approved protocol, 500 employees. The protocol got IRB-approved on a Tuesday. On Wednesday morning, we sent an email out to our employees that we were looking for 500 people. By the end of the day, we had roughly 3,000 employees volunteer to do the serology study.
And so, we found pretty much similar data to what Dr. Erin Kobetz [associate director for population science and cancer disparity at Sylvester and vice provost for research at the University of Miami] found in Miami-Dade County.
I don’t want to quote the data precisely, as we are trying to publish it, but a single-digit percentage of our employees tested positive. This study concluded some time ago, and the numbers are no doubt higher. We are planning on doing additional seroprevalence studies that will include university students, when the college opens up in August.
We have a four-pronged testing program in place to monitor our students for back-to-school. Currently, the university plans to begin school with a hybrid model, with some in-school classes and some online learning.
Have your Game Changer vehicles been put back into use? (The Cancer Letter, April 27, 2018)
I don’t think it’s in use. What would happen pre-COVID, is that when the Game Changer vehicle would show up someplace, it would draw a crowd.
We have been very concerned that the vehicle not be a place that would bring crowds together. However, the staff have been assigned to other duties, helping with our COVID-19 control efforts.
You were doing serology testing, which you put on hold because of an FDA action. Have you started using different tests?
We have validated other serologic tests, and we have found some that work well, including a point of care (POC) test.
To some extent, you have to read the fine print for some of these testing platforms. One serologic test says it is very sensitive “if used 14 days after the onset of symptoms.” Well, most of our patients won’t be tested exactly on Day 14, and so the assay doesn’t work “as well as advertised.” Even for PCR machines, sometimes it states that this machine is 100% sensitive if used within five days of the onset of symptoms. Again, this instrument may not be as sensitive when used in real-life situations.
We believe that there are cases where serology helps us. And we do have some plans for more seroprevalence studies, but we’re relying primarily on PCR-based virus detection methodologies.
And, obviously, there are lots of asymptomatic infections occurring, that nobody’s identifying adequately.
There’s no way to do it, really, at this point, except through more testing.
Right. We are working with Weill Cornell and several other institutions to conduct environmental testing, using PCR, trying to detect where the virus could be on the rise within our undergraduate campus.
This effort is part of a pretty comprehensive plan, that we hope will reassure faculty and students, and parents, that we are doing everything that the science permits us to do right now.
We are testing a variety of point-of-care devices that could give you results in 15 minutes; these may not be as sensitive as traditional PCR-based assays, but they still can be very helpful.
How has the cancer center been affected? What’s the impact on the cancer center?
We’re doing a lot more telemedicine, telehealth visits. As a medical center, we used to do maybe 100 a week, and now we do thousands a day.
Unfortunately, it was necessary for us to institute a no-visitor policy, which is really tough for our cancer patients and their families, but necessary. That’s still in place.
Given our robust in-house testing, we test everybody before they start chemotherapy, before they start radiation therapy, before they undergo a surgical procedure. The turnaround times for these tests is generally less than 24 hours.
That’s been very helpful, to get people evaluated and screened. We’ve had a few of our employees come down with COVID. But then again, oftentimes it’s traced back to their kids, as opposed to being acquired within the hospital setting.
Our hospital environment has been very safe. We’ve not had significant outbreaks; perhaps we’ve had a patient or two that’s gotten a healthcare worker or two infected, but it’s really very minimal.
We have some doctors who are quite concerned. They’re over 60 or 65. They may have health problems. We’ve been very accommodating to our faculty, to make sure that people don’t need to feel like they are jeopardizing themselves.
But especially as this goes on, it’s putting a great strain on everybody. We have lots of employees whose kids are at home, which, while typical for the summer, is problematic during the fall and winter. People are concerned about whether school will be delayed or not.
Actually, the Miami-Dade School District announced just yesterday that they’re pushing back the start of school a week. It now starts Aug. 31, and they are going to have only online classes until sometime in October. They will make another decision, probably in September, on what to do for the rest of the school semester. That will impact our ability to have all of our critical employees coming to work.
Everybody who can work from home is still working from home. The dedication of our people has been amazing—they really are heroes!
You mentioned that patients are back, but are they back in the same numbers as before?
The number of patients we are seeing is virtually the same as before.
In some instances, we actually have more patient activity than a year ago, even though it takes more time and effort to see a patient. For every patient we see, the staff has to put on PPE and take it off properly. Everybody who comes into our facility is given a mask.
Because there are no family members allowed inside our facility, it takes a lot more effort on our part. For instance, we have to help navigate the patient from the front door of our facilities to their exam room.
We have streamlined things for patients; we have eliminated waiting rooms at many of our sites of practice. Instead, you can wait in your car. We’ll text you and say, “The doctor’s ready to see you.”
And then you can come into the building, and you go right in to see the doctor. We have eliminated a lot of the chairs from our waiting rooms, but we decided to also eliminate almost all waiting, especially the sitting-in-a-chair waiting.
You mentioned that patient volume is up from last year, because of the designation, but do you have some guess on the numbers?
Compared to last year, we seem to be up about 15%. We’ve been growing by about 8% to 9% for quite some years. This year our growth is even more. But we’re very worried that there’s a lot of cancer out there that’s not being diagnosed.
I would say that our volumes are very good, and the number of chemo treatments we have been giving has been stable. If we’re down at all, it’s just a couple percent. Other parts of our health system were hurting, during the period when the governor declared there would be no elective procedures in the state, and that lasted for a few months.
We had to cancel a lot of surgeries. We had to institute some financial mitigation on the medical campus; top leadership took a salary cut, and the university chose not to contribute to our retirement accounts for this year. We have gotten some CARES money, which has helped. As is true at all other institutions, for many reasons travel is not allowed.
We are holding no in-person meetings. We used to serve lunch at some events and have recruitment dinners. So, I think we’re probably saving money on food, and I think we’re saving millions, because people aren’t traveling. Also, as none of our physicians are traveling, they are able to see some more patients. But, at some point, people have to take some vacation, and I think that’s been very tough for everybody.
I will say though that we continue to hire key cancer physicians and researchers, so we can advance our mission.
You mentioned that a lot of cancer is not getting diagnosed. How do you mitigate that later?
Our concern is that people are going to show up with more advanced disease, with metastatic disease or incurable disease. We stopped doing screening mammographies and colonoscopies for a while. Those were thought to be elective procedures; right?
A lot of screening hasn’t taken place. Also, people are afraid. People are afraid to donate blood. People are afraid to go to the Emergency Department for care. In the non-cancer arena, people are having heart attacks and strokes at home, because they don’t want to go to a hospital.
We have a confidence-building campaign. We need to get the message out that the hospital is a safe place.
Finally, this past week our numbers have started to come down. But throughout the pandemic we have stressed that if you come to see us, you’re not going to get COVID from someone in the hospital.
As you know, Sylvester has an in-patient facility that has 40 beds, which we use primarily for stem cell transplant patients, CAR T-cell patients and leukemia patients.
Then, we have the university hospital, which has around 400 beds. So, we don’t have any COVID patients in our Sylvester facility, and we have continued to conduct stem cell transplants and give chemotherapy and radiation therapy safely.
We have several floors of the university hospital that are strictly devoted to COVID. The COVID floors are on top. It’s an isolated area; people aren’t traveling through it. And we keep the COVID-19 positive patients in separate surroundings from the moment they arrive in the Emergency Department.
Have you done any cool science based on COVID?
We have been very involved with the COVID-19 and Cancer Consortium.
We have a manuscript about setting up our testing facility that’s available on medRxiv, entitled “A How-to Guide to establishing a SARS-CoV-2 Testing Facility Within an Academic Health Center Setting.”
We have been participating in driving convalescent plasma studies for patients in South Florida.
We’re also a major site for the Moderna vaccine trial, and, in fact, Vice President Mike Pence was here on Monday of this week to kick it off. We have several other vaccine trials in the pipeline, and several efforts to develop new rapid SARS-CoV-2 testing instruments or technologies.
Obviously, the diversity of our population is very good in any effort to understand the efficacy of the vaccine in different populations, especially in minority populations that may be at increased risk for having bad outcomes once infected with the virus.
And so, VP Pence and the governor and lieutenant governor of the State of Florida and the commissioner of the FDA came to visit us to help kick off this effort.
You’re a blood cancer doc, are you seeing anything from your perspective on this?
We and our colleagues are trying to figure out what are the key risk factors for COVID-19 disease in patients with hematologic malignancies.
I believe we are identifying some specific risk factors in myeloma patients and in CLL patients. Even though cancer patients are often elderly, we really haven’t seen specific groups of patients that are doing poorly.
What about your basic science labs? Are they back to being open? Is it difficult to reopen them?
The university asked every PI to submit what they thought was the critical research that was being conducted. For those with labs, that often meant animal studies, or COVID-relevant research. We have also been able to conduct cancer clinical trials that are critical for the health of our patients, but generally not those trials that require hospitalization.
And so, throughout the pandemic, we have been able to continue the mouse MDS and AML work that has been ongoing for a while. Initially, we were not able to breed new mice strains but more recently, things have opened up.
We were also asked how many people work in your lab and how much lab space do you have. So, roughly, six to eight weeks ago, we have been allowed one person for 200 square feet of lab space.
Also, to maintain social distancing, nobody in my lab is allowed to work more than 20 hours a week. So, we work seven days a week, and we stagger it, so we never have more than five or six people in the lab at the same time. Everyone has to have a mask on. You’re not allowed to sit at your desk and play with your computer. If you want to do that, you should be at home, working remotely.
My lab has maintained its two lab meetings a week, but we now do all this by Zoom.
It’s a significant difference, of course. Everybody’s been impacted, and everyone would love to get back to doing more, but the university is going back slowly, and, of course, we’ve been in the middle of this surge.
But the lab work is critical. Cancer clinical trials are critical. Also, we have some people at our university that are working on COVID specifically, whether it be viral detection or studying aspects of immune function. We’re all very anxious in the cancer center to get back to normal in the lab, but we don’t know when that’ll be.
Is there anything in your life that might have prepared you for this?
The only thing I would say is when I look back at my medical training, when I was an intern and a resident in the “days of the giants,” as they say. Hard work, focus, being willing to learn each and every day, the things that prepare you to be a physician, prepare you for dealing with emergencies like this.
Think of what we’ve learned about the science and the biology behind this infection. As our knowledge evolved, we have gone from an initial focus on surfaces, cleaning surfaces, to a focus on droplets and more recently on aerosols. We have identified some therapies that work.
Being a scientist is very helpful in all this.
But I do think that this is a once-in-a-lifetime thing. To see a pandemic that has killed more than 150,000 people in the United States, is incredible.
Is there anything we forgot? Anything we didn’t mention?
To wrap up, the only thing I would say is that the incredible teamwork that we’ve experienced at our cancer center, on a daily basis, has really been remarkable, as has all the hard work and long hours that people have put in.
We are continuously sending each other emails with information from medical journals, the FDA website, the CDC website, and other sources; the flow of information is incredible.
I think the message is that you can’t ignore the science; right?