publication date: Sep. 18, 2020
Conversation with The Cancer Letter
Barry Sleckman reflects on difficult months in Birmingham
Barry P. Sleckman, MD, PhD
Director, O’Neal Comprehensive Cancer Center,
University of Alabama at Birmingham
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.
On Jan. 6, Barry P. Sleckman’s started his job as director of the O’Neal Comprehensive Cancer Center at the University of Alabama at Birmingham.
It was the next logical career step for the scientist whose work focuses on understanding how DNA double strand breaks are generated and repaired. He had advanced from associate director of the Meyer Cancer Center at Weill Cornell Medicine to director of a storied NCI-designated comprehensive cancer center.
A month later, a moving truck bearing Sleckman’s beloved road bike arrived, and on a glorious day, Sleckman went out on a spin through Birmingham, a city where you can ride all year. A mile and a half into the ride, something happened. He doesn’t know what, and he hasn’t gone back to investigate.
Maybe the tire got caught up in some object, or, less likely, a car was involved. Sleckman ended up with a concussion and a broken left arm. The helmet was in smithereens, indicating that the outcome could have been much worse.
While Sleckman was on the mend, COVID hit Alabama.
“In April, like everyone else we were pretty much broadsided by COVID. Nobody was prepared,” Sleckman said to The Cancer Letter. “Everyone had to get prepared while dealing with the acute infections. So, now we know. We’ve seen.
“So, there’s a bit more information now, and plans in place. I’m pretty comfortable that if we could provide seamless cancer care during March and April, when it was just a war zone mentality, everywhere from the standpoint of understanding how to deal with it, we’ll be able to do it in the future.
“But it could raise challenges again. If we get a lot more infection here with the opening of schools, we may have to do things like close screening facilities temporarily, because of the potential risk. It’s possible. But I don’t think it’s going to influence care.”
Sleckman spoke with Paul Goldberg, editor and publisher of The Cancer Letter.
First, congratulations. I like to check in with the new cancer center directors quickly, but things have been pretty hectic for some reason. How has it been for you?
Barry P. Sleckman:
Overall—very good. I arrived in January, and then, in early February, the moving truck arrived with my beloved road bike. And they unpacked. The Sunday after that was a beautiful day in February. I was finally living again in a city like St. Louis, where I could ride my bike all year round.
And so, Sunday afternoon, I got my gear together, got out on the bike, got about a mile-and-a-half down the road, and the next thing I remember is a young woman standing over me with a cell phone asking if she should dial 911.
And I said, “Yes, please. I’ll pay for the call.” And, basically, I broke my left arm right up by the humeral head completely. The orthopedic surgeon—a shoulder doc—said it was the worst break he’s seen. And I now have 15 screws and a plate. And then, while recovering from that, COVID hits. So, if you consider it in that line, I’m doing pretty well.
Well, at least you got a mile-and-a-half ride out of it.
Yeah. I’m going to have to focus on golf now. But the problem, biking is good for me physically and mentally.
Golf is good physically, because I walk, but it’s not good mentally because it is a frustrating sport.
Things have been great starting this job. Getting to know people, getting to know what’s going on in the institution, what are the things you have to deal with right away, and what are the things that you can wait a little while to deal with. And then pacing yourself for the ultra-marathon.
One thing that has been very clear to me is that the administration of the University of Alabama at Birmingham School of Medicine and the UAB Health System and the UAB faculty are all very committed to the cancer mission, and there is great potential for growth here in both cancer research and cancer care. I am very excited about this.
As a new cancer center director, you are facing the challenges nobody has faced before. And COVID threatens to undo decades of progress in lowering cancer mortality (The Cancer Letter, June 19, 2020). I’m sure you are giving this a lot of thought.
That prediction from the NCI, that particularly in breast and colon cancer, there might be an extra 10,000 deaths over the next 10 years due to delays from COVID…
I think COVID touches the process in a couple of ways.
The most urgent was that some cancer patients were not coming in for care because they were afraid that they could be infected.
We’ve done everything possible to make sure that everyone here who needs care gets care—and got care even through the period after getting initially hit by COVID, while were putting procedures in place to mitigate the potential risk.
Even during those times—March and April—where a lot of elective procedures in the hospital were not being done, cancer care was still going at as normal a pace as possible, including therapeutic clinical trials.
And we kept all of the therapeutic trials—which are research, but also standard of care for cancer patients and often the only treatment option—we kept them open, except for those that the sponsors actually closed during that period.
But now, the cancer operation is essentially fully functional, with new methods in place to limit the potential risk for infection, of course. And a lot more telemedicine. If there is anything good that will come from this disaster, it’s that it really furthered our telemedicine efforts exponentially.
What would have likely taken 10 years to do at the slow regulatory pace was compressed into a month. And now, it’s a very common approach for taking care of patients that don’t require testing or physical exams.
We’re fully back in motion for cancer care right now. Now, that’s today. But, as I remind people, it’s still unclear what will happen in the next six months. In the next month, a lot of students are going to be returning to school. College students are going to return here, and kids are going to go back to school.
And if what some people are predicting occurs, then we could creep back up again. And if we start to have a much higher rate of infection and a lot of people in the hospital with COVID, then, of course, that will potentially compromise the care activities.
But again, the first things that will be compromised will be elective procedures, and cancer’s not really elective. It’s urgent.
Let’s go back one step here—to telemedicine. How much telemedicine do you do?
Right now, about 30% of follow-up visits for medical oncology are now telemedicine.
Is the billing okay? Are they paying?
Well, I can’t speak specifically to that, as from the professional fees. But, of course, if patients don’t come to the clinic, there’s no facility fee.
Okay, but like any other healthcare system, we’re space-crunched. We could see more patients, but in order to do that, we need more clinic space, and we need more physicians.
Our clinic space has been pretty much saturated in the past. But now, with 30% to telemedicine, that means that there’s potentially more clinic space, with the caveat that we can’t have the waiting room full of people due to safety issues.
Also, telemedicine visits still require the physician’s time. So, there’s that balance. We have a little more space, because people are not coming in, but we also need the physician effort to be able to now see new patients in that space and be able to do follow-up through telemedicine.
So, the bottleneck now becomes the physician—and it’s an opportunity for growth? Hire more physicians and do a greater volume?
Exactly. There’s always a bottleneck. It’s like a chemical reaction with multiple steps. There’s always a rate-limiting step. You can do something to fix that rate-limiting step, and that’s great, but then something else becomes a rate-limiting step.
There’s space, there’s physicians, there’s ability to promote access—and all these things have to be juggled up at the same time. You can’t just say, “Well, we want to double the number of patients we see, so we’ll hire twice as many physicians” without having the clinic space.
What can you do about the problem of potentially seeing another spike in cancer over the next decade? What can you do at UAB to get patients screened?
We have started that. Let’s just take breast cancer as an example. They closed the mammography facility in March and April, because, obviously, they had to get procedures in place to do it safely. And they simply put off the mammograms those months.
And what I’m told is that a lot of the women who were scheduled for those two months are now being rescheduled. They’ll be delayed a little bit. I can’t tell you what the probability that a two-month delay will lead to something that is not as treatable.
What we need to do is aggressively remind people that it’s important to be screened. So, if you missed a screening, talk to your doctor, whether you’re here or somewhere else in Alabama, and arrange for a place to go now that’s safe when it’s the right time to be screened.
And don’t just say, “Okay, I’ll pass this year and do it next year”.
I would imagine, without knowing how the epidemiologists at the NCI calculated that, that they probably had some assumptions. And some of those assumptions were probably that people would put off screening.
With a colonoscopy, you get that every 10 years. I just turned 60, so I need to tee up for one of those now. And if I said, “Okay, I’m going to pass now and wait ‘til I’m 70,” that would be a problem.
That’s a problem.
Also, remember that prediction was not just based on screening. They also considered issues around treatment and access to treatment in order to come up with that 10,000 additional deaths.
You have seen not one, but two spikes in Alabama. What do you expect in the coming months and how will it play out? Since you are an infectious disease guy, I should ask you how this thing will end.
Well, first, I would echo Tony Fauci. I’m not sure that we’ve seen two spikes. I think that it’s just a continuum. And I would consider it an equilibrium, and that equilibrium can be tilted by different events to either higher or lower.
And I think right now we’re trending down.
Certainly, the thing that I look at the most is the number of hospital admissions. The number of positive people that are coming up is dependent on how good your testing is, and how available it is. That’s a fact.
But the number of people in the hospital is a good indication of the number of new cases of people that are getting sick enough to be hospitalized. And that number crept up from April to mid-July, but now has been coming down, and I hope it will continue to come down.
I honestly think that we will live with COVID at some level until there’s an approach for it—a vaccine, most likely.
A drug, historically, seems less likely, but certainly possible. And we’re going to have to learn how to live with it. And we’re going to have to learn how to take care of patients with COVID, hopefully at a smaller level, for a while.
If you’re as old as me, you remember, back when AIDS came out, and it was really a catastrophic disease, initially striking young men with this pneumonia that would kill them. Nobody knew anything about it. Everyone thought it was probably infectious, and so, these people were isolated and whatnot, until we learned about it. And we still haven’t cured AIDS, but it’s a chronic disease now. And we’ve learned to live with it and take care.
Now, COVID is not a chronic disease, like HIV. But my point is in strategic planning, if we say, “All right, we’re going to plan on two years from or a year-and-a-half, there will be no COVID,” I’m not sure that that’s a sober strategic plan.
I think a better one would be to just try to do whatever’s possible to limit the number of cases and develop protocols for taking care of those patients.
But I think the next potential threat from COVID to cancer care for us, again, is this opening of schools. And we’ll have to see what happens. And if it does increase the number of cases and it increases the number of hospitalizations, that could impact our ability to provide care—obviously. Look at New York City during the peak. New York Presbyterian was completely full of COVID patients.
Right. So, what are you doing to prepare for this? Do you have any thoughts about how this needs to be handled nationally?
We have a great COVID team here, which is run by the health system. Actually, the vice president for cancer, whom I work with, was put in charge of a big piece of this, because he’s such an exceptional administrator. And so, they have a plan in place. They have a plan for testing. They have plans for increasing testing, if needed. They have contingency plans, like were put in place for April for using other facilities, if need, for patients and for procedures.
We’re hoping that those plans won’t have to be put into place, but I’m pretty comfortable.
In April, like everyone else we were pretty much broadsided by COVID. Nobody was prepared.
Everyone had to get prepared while dealing with the acute infections. So, now we know. We’ve seen. There’s lots of paradigms for cities that have had dramatic increases. There’s a lot learned from that. It’s talked about a lot amongst people who are leaders of health systems, how to deal with it.
So, there’s a bit more information now, and plans in place. I’m pretty comfortable that if we could provide seamless cancer care during March and April, when it was just a war zone mentality, everywhere from the standpoint of understanding how to deal with it, we’ll be able to do it in the future.
But it could raise challenges again. If we get a lot more infection here with the opening of schools, we may have to do things like close screening facilities temporarily, because of the potential risk. It’s possible. But I don’t think it’s going to influence care.
And as far as what’s going on in the rest of the country, I have no comment. Pick an area. I think that this—the face mask—is not an imposition on my personal freedom—and I wear it.
The amount of news in both the media and in social media, that is just all over the place from the standpoint of recommendations, is unprecedented. Most people are just confused, and they hold on to this idea, “Well, the healthcare experts are telling us different things every month. We can’t trust them.”
When I am asked by family members and friends, I say, “No, you can trust them. That is the natural course of understanding an infection.”
Again, if you go back to HIV when it first came out, for two years, we had no idea what it was. And people put things into place to try to limit that disease through experience. And then, through learning and through trials, but initially through experience. So, look around and say, “Okay, which countries have done the best?”
And then do what they do. Don’t ask why. Just do it.
How is UAB different from all the other cancer centers? What does it do that others don’t?
Well, you started by saying you’ve seen one cancer center, you’ve seen one cancer center. I’ve seen four—I was on the EAB at UCLA and Emory. I worked at Siteman and at Weill Cornell. That’s really my entire experience. So that’s four cancer centers.
Cancer centers require a broad spectrum of activities and expertise. I don’t want this to sound arrogant, but I think it can be more challenging, for example, than being a department chair, when you think of all the activities that cancer centers have to be involved in: basic research, population science research, community outreach and engagement, clinical care, translational research, clinical trials, healthcare policy. These are all very important areas that require completely distinct skill sets. So, you rely on having a great team of leaders with diverse expertise, which I am fortunate to have here.
Fundraising, too, right?
As you prepare for grant renewal, what kind of changes are you expecting to make?
I spent 17 years at Wash U. I was there when they got their first grant, although I was a little pup then, so I just helped write the immunology part and joined that leadership probably about four years after they got the grant. And continued there until I left in 2015.
One of the things that attracted me a lot to UAB was the similarity to Wash U. And that may sound strange, but in a way, it was like the challenges that are here were very similar to the challenges that I was part of at Siteman. The community is about the same size. The motivation of the community to have a cancer center in their community was similar.
The culture of the community not wanting to drive more than 10 miles to do anything, which is very important when you consider strategic planning for health care, as we learned in St. Louis, is similar. The institutional culture is quite similar. The notion that individual success is important, but the only way that we can do great things is as a team or group is quite similar. This has made me feel very comfortable and very much at home here from the start.
And lastly, and I think incredibly important for the next 20 years, UAB, like Wash U, is the only academic provider of oncology care in the metropolitan area. And I think this is critically important, because the care of cancer patients is becoming more and more academic.
Consider clinical trials 20 years ago: you got into a clinical trial, you had no sense really that it was going to benefit you. You were participating in the trial to help people learn about the cancer you had in a way that may help others who get the same cancer.
And if you did have some miraculous effect on your tumor, it was such an unusual thing that you were all the morning talk shows, talking about how amazing it was that your tumor went away.
But with the advent of immunotherapy and other therapies this changed…
Actually, one of the first real targeted therapies was Gleevec—not to take anything away from that—which I think was huge. Something where knowledge of the molecular basis of a cancer was used to treat the cancer. But then, going on to immunotherapy, people with lethal cancers are walking around today, because they were in a clinical trial. People with non-small cell lung cancer, people with metastatic melanoma, walking around, because they were in a clinical trial.
When friends call me and they say, “Well, so-and-so has cancer. They went to see their doctor,” I always say, “Did the doctor say anything about clinical trials?” And if they say no, I say, “You go find another doctor.”
Because to me, offering a clinical trial is really part of the standard of care, and it’s not just for people who fail upfront treatment now. Immunotherapy is given with standard of care treatment upfront in trials, and some people on these trials are having good outcomes.
My point is that, to just say, “Okay, I have a small nodule in my breast, stage I breast cancer. I’m just going to be treated locally. It doesn’t matter.”
Twenty years ago, that was probably true. But now, you might go to a cancer center, where they say, “You have a great prognosis, but 5% or 10% of people with really benign lesions will recur five or 10 years down the line. And we have a trial. Maybe a personalized vaccine trial, where we’re looking to see whether this will decrease the rate of recurrence. Would you like to participate in that?”
That’s just a hypothetical example, but people participating in that may end up not recurring five or 10 years from now as a result.
So, I tell everyone, “You should at least be seen at an NCI-designated comprehensive cancer center, no matter how trivial your cancer is. Just go and listen to people who are going to tell you about potential trial opportunities that may help you now, or mitigate potential recurrence years down the road.”
You have a catchment area that’s just enormous, a lot of Deep South. How do you manage that?
First of all, we must be dominant in the Birmingham metropolitan region. I think that people always want national recognition. Every institution wants to be nationally recognized; right?
But, we need to be locally dominant first? It’s very hard to be nationally recognized if you’re not locally dominant providing the very best care to the people in our own back yard.
The real responsibility of this cancer center is to Alabama and then next to Mississippi. We would love to take care of anyone in the country, but Mississippi is really the carbon copy of Alabama when it comes to cancer. You consider Alabama and Mississippi together, and look at the statistics, it’s bad for many common cancers. Smoking and lung cancer, prostate cancer, breast cancer. So, I would say that a goal would be, number one, make sure that we can provide NCI-designated quality cancer care to Alabama. And then, potentially, extend to Mississippi. People in Mississippi really do not have easy access to an NCI-designated cancer center for their care, so we need to do whatever possible to fill this void.
And I would say something about catchment, which I think is important. The O’Neal Comprehensive Cancer Center was one of the first eight in 1972. And I think Alabama’s a catchment area, because we’re in Alabama—the entire state.
If you look at some of the old cancer centers, [they cover] the entire state. But, given what is expected of a cancer center to work in a catchment area, it’s very challenging to have the whole state be your catchment area and to be able to provide cancer care to everyone across the state.
And we’re working as hard as we can. We get people from all over the state, thanks to the health system developing affiliations where we can provide cancer care and in particular cancer trials. Providing these clinical trials is still a work in progress, and it will be.
I’m actually kind of excited about that, because I watched that happen as Siteman, where they expanded their reach in Missouri, and so, I think I understand the roadmap for making that happen here.
Has COVID had financial impact on UAB and at the cancer center level, and how are you managing it?
I can’t really speak to the financial impact on UAB. I think it will depend a bit on how they will traverse the students coming back, because institutions derive a lot of revenue from students. And not just students taking courses online, but student activities, eating in the dining halls, and all that.
So, I think it’s still an unknown how much it will impact the institution. It impacted the health system quite a bit, but then some of that was offset by the federal relief for COVID.
For the cancer center, I think that the potential impact could be in raising money for special programs, like pilot grant programs, clinical research programs. We have several events every year to raise money for the cancer center, which I’m sure you can imagine have been turned into Zoom events.
For strategic purposes, we are projecting that we will end up making about half of what we made in the past.
Now, before you say, “Oh, my,” that’s just, for me, a worst case scenario. We need to come up with an idea of how much money we’re going to have to invest in pilot grants and whatnot.
From some sources, we plan for half. I don’t think it’s going to be worse than that. So, I’d like to know what’s the worst-case scenario.
I think that we might have to tighten the belt a little in the next year or two, but I think we’re going to get past that.
Well, the cancer center is the part of the institution that makes money still. So, you might have it easier, you would think.
I think you have to consider revenue from different sources. So, there’s patient care revenue, and then that goes into recruiting and all.
But what I really consider is the most important thing that a matrix cancer center does, is to support initiatives that faculty have started around the institution, which are things that are moving up. And then the cancer center comes in and just catalyzes that to move at a more rapid rate.
And it does it through pilot grants, to allow people to use shared resources, through supporting clinical trials activities, through all of that. And we use monies that come from endowments, monies that come from grateful patients, and monies that come through fundraising events, either our own or philanthropic groups that we work with, like the Breast Cancer Research Foundation of Alabama, Mike Slive Foundation and the American Cancer Society. As you know, some groups like ACS are struggling now.
Yes, it’s struggling (The Cancer Letter, July 24, 2020).
To say the least. Foundations that raise money through events are all going to raise, probably, less money over the next year or two. But I think we just need to get a picture for what we think the worst-case scenario will be, and then we plan for that, and we’re happy if it’s anything better than that.
That’s a good way of looking at it. What role can cancer experts play in COVID research? In March, The Cancer Letter was writing a lot about it: there was a lot of discussion about the convergence of oncology and immunology and infectious disease. So, it’s September now. Has this convergence occurred? It is occurring?
Well, I think the convergence you talk about will be quite a while, before it parses itself out. You ask how does oncology influence COVID? Anybody can work on COVID. Scientists are smart people, and if they think they have a good idea and you’re willing to give them some money, they’ll work on it.
So, there are a lot of people working on COVID now that are not virologists or immunologists, or anything like that. So, I’m not going to comment on that.
But I would say that one important area, of course, especially if COVID is with us for a while, like it might be, without a vaccine, even at a low level, is obviously, how does being on immunotherapy impact your ability to deal with COVID?
So, that is an extremely important question that will need to be figured out, if in fact COVID exists in our environment for years to come.
So, what would it mean to be on checkpoint blockade or CAR T-cell if you’re exposed to COVID? Would you be a lot worse off? And that’s something that I know people are starting to look at now, and there are various proposals to study that.
And then, the other influence, of course, is sociologic, which is, especially in Alabama, where there are a lot of underserved patients in communities that may not be as well-informed, and they may just generally be afraid to come in.
So, there has to be a certain amount of education, and we’re doing that now. Actually, we got a supplement from the Cancer Center Support Grant to do exactly that. And so, there is a process in place to start to educate underserved populations about getting appropriate cancer screening and cancer care in the setting of COVID.
I think those are two areas where oncology definitely crosses over with COVID. And there certainly could be plenty of people that were doing cancer research who think they have a great idea about COVID. I hear that a lot of my previous colleagues, who were working on cancer research, are doing COVID work. That’s great.
They’re smart, they think they have a good idea. Who knows? Perhaps they’ll come up with something good.
Has NCI been helpful through this?
Been helpful with the COVID issue?
Just surviving this.
When all this hit, a lot of institutions, including our own, said, number one, stop basic research, because it’s a risk to have people in the labs working together. And then the question was whether we should stop clinical trials, too. This can often be the mindset. “Oh, we’re going to stop clinical research, too.” Many people think the clinical trials is research, so it can be put it off too.
I jokingly say to people that the real problem with the Clinical Trials Office now is that it’s called the Clinical Trials Office. It should really the Innovative Therapy Office, and people would think of it differently.
Clinical trials, when you say that to some patients, they think, “Oh, you’re going to do an experiment on me, make me a guinea pig.” When you say it to administration, they say, “Oh, that’s research. I got it. It’s important, but if we have to stop it it’s no big deal.”
The NCI came out on their website with a clear statement that they consider, as hopefully more and more people will, that they consider cancer clinical trials to be part of therapy, and in some cases the only thing we can offer to patients.
So, they said, “Look, you have to do what you have to do, but we would recommend that you do everything possible to continue to offer therapeutic clinical trials to cancer patients through COVID.” And we did.
Our institutional leaders agreed with this and we continued to keep as many cancer therapeutic clinical trials open as possible. Our accruals went down in March and April. But they’re back up now, and we did everything we could. So, I think that’s something that the NCI really helped with.
The NCI also got money through the Paycheck Protection Program and has been able to fund grants that are related to understanding both the sociologic and the biologic intersection between COVID and cancer and that has also been important.
But I think the most important thing they did was the messaging about trials and cancer care.
What about basic science?
Cancer, and maybe COVID. In your institution right now, are you coming back up?
We’re back up. There are still protocols about the number of people in lab, social distancing and limiting in person meetings to limit risk. This is perhaps not the best thing for basic science, but it’s the best thing for our health right now. Hopefully we’ll eventually get back to the point, where people can sit around the coffee machine and talk about crazy ideas that become important scientific discoveries. But, for now we are moving forward and that is good.
Is there anything that we’ve missed? Anything you’d like to add?
In this day and age, it really matters where you’re treated first. And I’m biased, because I’m a cancer center director. But I think more so than even 20 years ago, it really matters to be seen in an NCI-designated comprehensive cancer center.
And so, with that in mind, one of the big challenges for us, and, I think, actually, an emphasis of the current leadership at the NCI, the program leadership at the Cancer Centers Program, is to be able to make that care available to everyone in your catchment area.
So, we used to say in academic medicine, “Well, if you come here, we’ll take care of you.” And the reality is, not everyone can come here. They can’t, for one reason or another. Could be geography and other barriers, etc.
And so, we have to work through our outreach program and through the health system to be able to make cancer care accessible to everyone and available to everyone in our catchment area, and for us that is the state of Alabama. This will be a main focus for us for the next 10 years.