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.
Nancy Davidson is now in the eleventh week of managing the COVID-19 pandemic—the longest stretch experienced by any health executive in the U.S.
And now, like her peers throughout the country, Davidson, president and executive director of the Seattle Cancer Care Alliance, is in the midst of ramping up plans for a comeback of cancer services.
The Cancer Letter asked Davidson to discuss these plans and share her thoughts on the way cancer care will evolve both at SCCA and nationwide.
This conversation is part of an informal 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:
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).
Washington was the first state to record what at the time was believed to be the first COVID-19 case—on Jan. 15, in a traveler from Wuhan, China.
Washington was also the first to register what appeared to be the first COVID-19 death, and SCCA as well as Fred Hutchinson Cancer Center, a component of the alliance, were the first major cancer institutions to take decisive action and shut down non-essential operations (The Cancer Letter, March 13, 2020).
At this writing, the state of Washington has 18,964 confirmed cases and 991 COVID-related deaths. The disease peaked weeks ago, and the spread has slowed. On May 15, for example, 101 new cases and 5 deaths were reported in the state. Washington ranks 18th in the number of cases.
Now, SCCA is among the first to make plans to reopen its operations.
“We are bringing our stem cell transplant and our CAR T programs back online in a very thoughtful way, and there’s a lot of pent-up demand for that. We had over a hundred transplant patients who’ve been waiting in the queue, for example. And so, we’re beginning to recall them and bring them in,” Davidson said to The Cancer Letter.
“We looked at things like imaging, close to a thousand mammograms that didn’t take place because screening mammograms were paused during this time of maximum separation. And so, we’re also beginning to think about how we can thoughtfully recall those patients. Some patients who had more elective therapies also put it off for a while.
“And so, we have a pretty good idea of what the numbers are. I mean, you’re right. We are actively reaching out to patients and letting them know that the system was always safe. But we’re now at a position where we think that they can safely come for their in-person care.
“And I think that’ll be an important thing going forward, especially in cancer. You and I know that cancer didn’t take a pause during the COVID pandemic, and it isn’t taking a pause in the near future. We really need to be in a position where we can try to optimize our care going forward. We do know that some of our patients are worried. They’re concerned about the possibility that they would somehow increase their exposure by coming in to their visits. And so, we have very, very robust testing in place in Washington. That’s also helped us.”
Davidson spoke with Paul Goldberg, editor and publisher of The Cancer Letter.
Paul Goldberg: You have more experience with more phases of COVID-19 than anyone else in the U.S. So, going back to the beginning, to what feels like a decade ago, you moved very, very fast and set up prioritization, and closed things down. What was it like to be on the inside of those decisions?
Nancy Davidson: Paul, you’re right that we’re in the 10th week of our pandemic response at the Seattle Cancer Care Alliance. As you point out, we are the first of the United States NCI-designated comprehensive cancer centers to experience this in a meaningful way. And at the time, I think that we knew that we were entering into uncharted territory, but territory that we were well equipped to deal with.
As you point out, we’re in a state that has had a very robust response.
We work at an institution that has a lot of people who are already involved in research in viruses. Fred Hutch houses one of the big coordinating centers for the HIV vaccine efforts, so that we felt that we were in a good position to do this, but we were kind of learning on the job.
Oncologists, though, are very good at dynamic situations, and tackling risk; right? That’s what we do for a living.
Well, you have also seen more impact on your institution and research, both clinical and basic. How would you summarize this impact?
ND: We have seen much more impact than all of us would like on our cancer research.
Obviously, our COVID research is flourishing right now, but on the cancer side, we made the decision institutionally, across Fred Hutch and Seattle Cancer Care Alliance, to really slow down our basic laboratory research in accordance with the state guidelines and with our own modeling about what we should do to try to flatten the curve.
And we also made the decision to really limit access to some of our clinical trials, particularly the phase I clinical trials, where we felt that the real goal of a phase I trial is toxicity rather than improving patient wellbeing. And we also closed some of our phase III clinical trials, because we felt that a standard treatment option was available for those patients.
But Paul, we’ve continued our phase II clinical trials all during this time, for patients where we thought that clinical trial participation would be important for their wellbeing, and we certainly have continued care on trial for everybody who was already on trial. The new accrual was limited more to folks who were going on to the phase II trials.
And we’re now doing the reverse.
We’re at a point where we’re able now to think about how to wind up after the wind-down. And so, right now, we are, in a very thoughtful and deliberate fashion, opening about 10% new trials and 10% of our closed trials over the next week or so.
We’ll look carefully at the impact of that, and then we hope to continue that ramp up in a stepwise fashion. And we’ve tried to prioritize those for trials that are in patients’ best interests, trials that really reflect some of our primary research interests as an institution, and those where we think that we can try to optimize the safety of the participants and our staff.
Do you think anything has been irrevocably lost, in terms of data?
ND: I think that in some of our clinical trials, we weren’t able to collect every single piece of data that might’ve been mandated by the clinical trial.
Certainly, we were able to collect all the data that would be vital for patient safety. And we may not be able to get all of those things, but I suspect that for the clinical trials that have remained in operation and those that will be restarting, that we’ll be able to gather the information that we need to address the primary aims of the clinical trial.
I’ve heard it said that with randomization, problems affect both sides of the trial. So, with randomized trials, you might actually be in okay shape.
ND: I think so. Many of the randomized trials are very large trials; right? And one would hope that what we’re going to see is a short period of a pause, and then, you’re right, the trial will resume in its full form, and that we will not have any compromise of the primary outcome of the trial.
What about clinical care? Has that been set back?
ND: No, I don’t think so. I do think that oncologists are pretty good at dealing with adversity, as are our patients. So, we have remained operational the entire time. We’ve actually used this as an opportunity to accelerate some of the initiatives that we probably should have done before.
All of us have become very adept at telehealth now, and we are hoping that we’ll be able to right-size how we would use that going forward. And, of course, we’re hoping that the reimbursement strategies nationally will make that a viable alternative for some patients where it’s appropriate.
We continued all of our infusion therapies, by and large. The one place where we made some pretty strategic decisions was to slow access to our cell-based therapy trials and treatments, our CAR T trials and our stem cell transplant trials.
As members of a healthcare ecosystem, we needed to be in line with the priorities of the state of Washington and the Puget Sound region at the time, to make sure that we freed up inpatient beds and critical care resources for what we thought would be the surge of COVID-19 patients.
And so, that meant that those transplant and CAR T patients were the patients who were the most likely to require those things, and we made the decision to slow their entry into our system. We’re now restarting that, too, Paul. As of last week, we’re reentering some of the most needy patients who require those particular kinds of interventions, because we feel that we have the hospital capacity to care for them should they become ill.
Have you had to do triage on COVID? On, say, ventilators?
ND: Thankfully, we have not. I think, again, the state of Washington has been very forward-thinking on this. In our state, early on there were a lot of workplaces that put people to work from home. The Fred Hutch and the SCCA did this early on; the governor has been very diligent in the state of Washington.
And so, I think we were in happy circumstances where, thankfully, our critical care capacity was higher than our needs. And so there was never a time that I’m aware of where in the University of Washington system we had to triage the use of ventilators.
What role have disparities played in this crisis?
ND: Well, gosh, I think that’s an area where we’re all trying to sort it through; right?
Our region has a large homeless population. That’s certainly a major form of disparity. And so, I think that within the region, we’re trying to work collectively with our government facilities and with our partner organizations to make sure that our homeless population has access to the kind of care that they need across the board—things that are related to prevention or treatment in COVID, as well as underlying social and health problems that they might have.
Ours is a state that has a large Native American population, and so, we’re trying to make sure that we work pretty actively with our tribes, where appropriate, to make sure that they’re getting the appropriate health care.
And you may know that also in our region the Yakima Valley, which is in the middle of the state, is the home of our larger Hispanic population. That region has been particularly hard hit, and I think that might have to do with the nature of the workforce and the kinds of jobs.
These are folks who often work in situations where it’s hard to distance in the workplace, and they work in vital industries, and so, this is a population that’s also been especially hard hit. So, we’re trying very hard to make sure that we understand these individuals who are at particular risk, and we do everything we can to try to mitigate that risk within those individuals.
How soon do you think you might have some data?
ND: I don’t have a good answer for you on that one right now. I think that everybody is pedaling as fast as they can, Paul, to try to get data generally. And then, also, for specific populations.
For example, populations of patients with cancer.
AACR had a session where they tried to review what we know about cancer as a risk factor for COVID, and it looks to me like we don’t have a clear understanding of that as a field, either. So, there are a lot of places where we have knowledge that we really have to gain over relatively short period of time.
What about financial impact? Have you had to have furloughs or any other forms of belt-tightening?
ND: We think our workforce is incredibly important. That’s obviously one of our most important resources, and so, we’d like very much to retain our workforce as best as we can going forward. We’ve been fortunate that many people were in a situation where they could work from home.
And so, many of our workforce members who don’t have to be physically in the office or who are not directly patient-facing are working from home and they’re working extremely hard.
I think it will be interesting to see how it goes over time. What the healthcare workforce looks like generally is something that we’re all going to need to be thinking about as we go into the months and the years ahead—what we’ve learned from this, and what we can use to try to optimize the delivery of healthcare going forward generally, and also the delivery of cancer care specifically.
People talk about a rebound in demand for care—patients showing up saying, “Take care of us.” You should probably be starting to see it about now, I would think. Is it happening?
ND: We are hoping that we’re going to see that shortly, and, actually, we’re trying to begin to promote that, if you will.
First, I told you about the fact that we are bringing our stem cell transplant and our CAR T programs back online in a very thoughtful way, and there’s a lot of pent-up demand for that. We had over a hundred transplant patients who’ve been waiting in the queue, for example. And so, we’re beginning to recall them and bring them in.
We looked at things like imaging, close to a thousand mammograms that didn’t take place because screening mammograms were paused during this time of maximum separation. And so, we’re also beginning to think about how we can thoughtfully recall those patients. Some patients who had more elective therapies also put it off for a while. And so, we have a pretty good idea of what the numbers are. I mean, you’re right. We are actively reaching out to patients and letting them know that the system was always safe. But we’re now at a position where we think that they can safely come for their in-person care.
And I think that’ll be an important thing going forward, especially in cancer. You and I know that cancer didn’t take a pause during the COVID pandemic, and it isn’t taking a pause in the near future. We really need to be in a position where we can try to optimize our care going forward. We do know that some of our patients are worried. They’re concerned about the possibility that they would somehow increase their exposure by coming in to their visits. And so, we have very, very robust testing in place in Washington. That’s also helped us.
And so, we have a really good idea about the relatively few members of our staff who have tested positive, and also, the reasonably small number of patients have tested positive. Great testing capabilities, so if anybody’s symptomatic, they get tested immediately through our drive-through testing facilities that we’ve set up.
Do you test everybody who walks in through the door, every patient?
ND: No, we don’t test asymptomatic staff or patients, with rare exceptions. We are now doing testing in individuals who are being teed up for stem cell transplant, for example. Our surgeons are now doing routine testing on anybody who’s slated to go to the operating room.
Our proceduralists are doing testing on anybody who’s going to have a kind of procedure that might have a higher risk of infection of bystanders. We’re trying to use testing in a very, very thoughtful way, to identify patients who are going to go through some sort of procedure where we want to understand it for their risk or we want to understand it for the risk of the caregivers around them.
How many patients had the disease while it was peaking? What’s your cumulative for COVID?
ND: Could you say that again?
How many COVID patients have you seen through the system do you think?
ND: In the system? I don’t have that number at the top of my head, but I can tell you in the Seattle Cancer Care Alliance that I think a minimal number of staff members have tested positive over the entire time.
What about patients coming through the institutions?
ND: We’ve been fortunate that the infection rate in our patients is quite low, and it’s not out of a context with what we see in our community at large. And in the state of Washington right now, I think, about 7% of tests are positive.
How many of the state’s, what percentage of the state’s cases have gone through Seattle Cancer Care Alliance Institutions?
ND: Although I don’t have that specific percentage, the number of infected patients at SCCA has remained minimal.
As you watch the debates about reopening the country, what are your thoughts? How should this happen?
ND: Oh , that’s a pretty tough question, and one that obviously there are people who are at a higher pay grade than me who are doing this for our national interests.
I think within the state of Washington, we’re trying to work very closely with our government authorities, with our governor, Jay Inslee, with our fellow healthcare providers, and, actually, we’re also working with some of our big employers around town.
This state has chosen to be very thoughtful and very deliberate, in part perhaps because we were in the vanguard, and we did take steps rapidly, and we thought that we could see a very positive impact in what we were able to avoid as a consequence of these measures.
I think that across the region, there is actually an effort to think about how we’re going to do this together across all of these different constituencies, and to try to come to some sort of agreement about how this is going to change, and to know that it’s going to be dynamic, Paul. And also, that it may be somewhat regional.
The state of Washington is one that has some pretty rural regions that haven’t been especially affected by COVID. We have some pretty urban regions, like Seattle, and the Puget Sound area obviously was a real epicenter for it.
And so, it might be that the thoughts about how you do that are going to change a little bit, depending on where you are in this state. The governor looks at this very actively. He has just opened up some of the state parks, for example.
Right now, I don’t know that he’s going to make other major pronouncements about other changes until more towards the end of the month. And we’re trying to work with him to make sure that we are all one state trying to address this in the most effective way.
Well, it helps you have better public health systems than a lot of other states.
ND: I think we’re very fortunate that the public health departments here have been very active early on. They had to be, they were thrust into the center of it, with the nursing home and the Evergreen Hospital, and the fact that we had what we thought at the time was the first death within the state of Washington, the first death within in the United States.
We now know that that may not have been true, because there are these other cases that are turning up.
But you’re right, I think the public health infrastructure here is quite strong. The public health interest is quite strong, and I think that we’ve been fortunate that people have been willing to work together on this.
From a health point of view, remember that healthcare was always essential. And so, there was never any effort to shutter healthcare across the state. It was kept running, and the only thing we did was to make some of the modifications that you and I just talked about at a time that we felt when we needed to be ramped up in case there was a very major surge of people who needed inpatient care, especially intensive care.
And we were fortunate that we avoided that. I think one of the things going forward for all of us is to recognize that we’re probably going to have some COVID infection for quite some time to come, and so we have to think about how we’re going to work effectively to hopefully maintain that at a low or even lower level, but also to be able to ramp up our medical care to make sure that we address some of those unmet needs that you talked about.
What will oncology look like when COVID is over?
ND: Well, I think that cancer is not going away, or cancers are not going away. So, I think those big things are not going to change; right? The needs are not going to change. I think our therapies are not going to change, so far as I can appreciate.
The interesting things that we’ve been thinking about are, first of all, maybe the location for some services. Oncology tends to be pretty resource-oriented. We often have a need of testing, we need a blood drawing, we have need of infusional capacity, we have need of radiation oncology. So, I can imagine that those things are not going to change, and it may not be possible to do all of those things in a remote fashion. In fact, for many of them, I think, it’s going to be tough to do.
But what might change would be some of the things that are involved in longer term care, long-term follow-up. And I also personally wonder whether it’s going to depend a little bit on the kind of cancer.
For example, Paul, as you know, I’m a breast cancer specialist, and I tend to like to see my patients in person for follow up, because we want to do a physical exam and cannot do that remotely.
So, I think one of the things we’ll have to contend with as a field is what things do have to be done face-to-face, hands on patient, or test on patient, and what things might be able to be safely and efficiently changed over to telehealth, for example.
What do you think about this new emphasis on, maybe it wasn’t the case at Seattle Cancer Care Alliance but elsewhere, on neoadjuvant treatments instead of adjuvant? Is that a good thing or not a good thing for the patient?
ND: I think that I can speak in a most informed fashion from the breast cancer perspective, because that’s the area I know best. And I would tell you, Paul, that I actually was one of the first proponents for it.
I happened to be in our multidisciplinary new patient clinic for breast cancer patients, just at the time that this was all starting, and we happened that day to see several older women with very small receptor-positive breast cancers, where, first of all, we would wonder that they might be at slightly higher risk for COVID because of their age.
And second, we felt that their breast cancers were such that one could safely provide an aromatase inhibitor endocrine therapy for a few months, and then do their surgery at a later date.
I was a pretty strong proponent of that, where it was medically appropriate, in order to try to allow patients to receive effective therapy, but also to minimize their need to present to the hospital setting at a time when we didn’t know exactly what it was going to look like.
And also, to minimize their own personal exposure, to allow them to stay at home. I think it’s gone well. I think that the doctors and the patients were very thoughtful about doing this together, that they focused on what was best for that patient, her cancer and her as an individual.
And so, I don’t believe that any patient had the delay of therapy, or a change in schedule of therapy that threatened their long-term outcomes in any way, shape or form.
In fact, I can tell you those first couple of patients that I saw—it would have been on March 1, give or take—they’re going to the operating room right now, having done fine, and now in a position where everybody feels very good about their ability to go through surgery with all the resources that they need and to promote their recovery.
So, is there going to be a way to learn from this? Or to have this approach adopted, maybe, for the future?
ND: I think that’s an interesting question. I think you know that there are several groups that are trying to do COVID and cancer registries of one sort or another.
A lot of efforts going on right now across a variety of organizations, and I think it would be nice to see whether or not we could harmonize that in some fashion where we could learn about what you just talked about, both with regard to what does COVID mean to the cancer patient, but also whether there’s anything that we can learn about their cancer treatment and its outcomes, because of the way it was modified during this pandemic.
I don’t know if that’ll be possible. It may be that we won’t have sufficient number of patients, thankfully, to be able to learn from. But it’s an interesting question Paul.
Neoadjuvant therapy, as you know, was already a mainstay for many types of cancers anyway, and so, I think that it’s something that we were already pretty comfortable with in certain circumstances and this has probably helped us to feel even more comfort.
We didn’t talk much about basic science; how has it been affected? Labs have been locked down for months.
ND: I think that’s been pretty tough for our basic scientists, because you’re right. Our clinical care individuals are in the workplace every day, taking care of patients; our clinical and translational researchers saw a slowdown, as you and I talked about, because of the fact that we limited a pool of new patients to clinical trials, although we continued the treatment and follow-up with those who are on existing clinical trials.
For our basic scientists, from the beginning, there was the recognition that we would need to have baseline staffing of labs to make sure that lab function was maintained.
And so, the labs never totally—quote—shut down. What’s happening now is that we’re slowly but surely allowing our laboratory scientists to come back into the labs in a way that again maximizes their physical distancing and still allows them to continue their work and to be able hopefully to ramp up their work.
Many of them, as you know, have tried to do what they can in terms of research from home, and so a number of people have done their writing, have done a lot of their thinking. They’ve done their grant writing. But I think that everybody is very much looking forward to coming back into the labs in an ever-more populated fashion, but one that is protective of their health.
There’s got to be something to learn from COVID and, of course, your institution is in a great position to learn from it.
ND: Yes. I think that also the people who worked pretty much full tilt were the number of labs who were already in some sort of virology research, as well as those who turned some of their activities towards COVID research. So those labs have operated at full tilt all during this time.
Is there anything we forgot to address?
ND: No, I think that the word “unprecedented” is pretty overused right now; isn’t it?
I think one of the things we’ll have to contend with as a field is what things do have to be done face-to-face, hands on patient, or test on patient, and what things might be able to be safely and efficiently changed over to telehealth.
But Paul, I feel like in the medical field since I’ve joined it, we had the period of HIV some decades ago, where we had so much uncertainty and lack of clarity about what was going on and how to proceed. And here we are, some decades later, with a lot of wonderful progress that has been made against HIV, and still some opportunities.
It seems to me that the swine flu a decade ago presented some of the same challenges. And there’s no question that this has been incredibly complex for all of us, and I think we have come out, or we will come out of it stronger. We’ll know more both in terms of the cancer care world, and also in the infectious disease world, and hopefully in the public health realm.
And this probably isn’t the last time we’ll be confronting this. And I am hopeful that we as a society are going to be more prepared than we were this time, and we’ll be able to learn from all of our progress this time and have an even more effective response in the future.