This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. Our full coverage of SARS-CoV2 is available here.
Last time Ruben Mesa spoke with The Cancer Letter, COVID-19 was under control in San Antonio and the environs—or so it seemed (The Cancer Letter, April 22, 2020).
That was late April, before the bars reopened, before inner tubing returned to the Comal and Guadalupe rivers, before the young, the cooped up, and the ideologically motivated took off their face masks.
“The age range does seem to be different for this surge versus what we had earlier in the spring. So, many more in the 20 to 40 age range have been affected,” Mesa, director of Mays Cancer Center, home to UT Health San Antonio MD Anderson, and Mays Family Foundation Distinguished University Presidential Chair, said to The Cancer Letter.
“Additionally, the percentage of individuals that end up in the ICU or ventilated is clearly less. Now, it’s still a significant number, but at least proportionately, it seems less than at the peak,” Mesa said. “Perhaps improvements in management may have been part of that, as well as the younger ages. So, earlier use of dexamethasone. Our center has been very actively involved in the remdesivir study and accrued a large number of patients in that. So, that may have helped improve the mortality and severity of this spike.”
Mesa spoke with Paul Goldberg, editor and publisher of The Cancer Letter.
Paul Goldberg: Last time we talked, you were pretty much done with the peak of COVID—and look at what’s happening now…
Ruben Mesa: Well, it’s very unfortunate in that by far, we have many more patients now than we had at the “peak.”
To give you an example, the current inpatient census for our clinical-partner hospital for COVID is 170 today. In the middle of March and in April, it never got over 40. That’s not the city, that’s just our partner hospital. But dramatic, dramatic spike.
Of course, that clearly matches both the city and the State of Texas, of which my understanding, probably Harris County, in Houston, seems to have it the worst. But it’s clearly a huge issue across the entire state.
What happened? What’s your sense of it?
RM: I think, without question, Texas likely opened up too early, and the approach to opening up, I think, clearly did not help to control the virus.
The mandatory masking orders—and I think there were several high-risk venues, in particular bars and other social areas—that I think with contact tracing they found have really been very impactful in terms of sharing the virus.
So, they’ve pulled back on those things. There was inner tubing on the rivers, which is a big thing around here, and that too has been closed. So, I’ve not heard direct data, but I can’t help but think that they have found outbreaks that have been associated with that, and the bars, and clearly not enough mask-wearing.
Who’s harmed the most by this? Is it still the underserved, or is it people who have extra money to go to the bars and party?
RM: I think in terms of social demographics, without question, the underserved continue to be affected. The age range does seem to be different for this surge versus what we had earlier in the spring. So, many more in the 20 to 40 age range have been affected.
Additionally, the percentage of individuals that end up in the ICU or ventilated is clearly less. Now, it’s still a significant number, but at least proportionately, it seems less than at the peak. Perhaps improvements in management may have been part of that, as well as the younger ages. So, earlier use of dexamethasone.
Our center has been very actively involved in the remdesivir study (ACTT2 remdesivir +/- baricitinib) and accrued a large number of patients in that. So, that may have helped improve the mortality and severity of this spike.
So, everybody gets steroids now?
RM: I think the criteria continue to evolve, but clearly, those that are hospitalized with significant inflammatory features and almost all ICU patients receiving dexamethasone or methylprednisolone.
Additionally, I think we’ve learned throughout this process, I say, we, the broader U.S. medical community, about the use of anticoagulants to decrease the risk of thrombotic events.
So, I do think there’s many aspects of management, independent of antiviral therapy that have improved as the pandemic has evolved.
Do you do dialysis as well?
RM: Clearly, if they’re in renal failure. But, clearly, respiratory is the main difficulty that individuals are having.
What about remdesivir? Do you have enough of it?
RM: For the time being, yes. Although, I know there are clear concerns about the supply moving forward. There had been first the trial, which now has completed accrual. Then there was an emergency use aliquot. Then, now it’s really relying on commercially available drug.
I think we are set for the moment, but that is a significant concern. There’s significant hope that we will see this surge improve. The rate of increase in cases, at least in the San Antonio area, does seem to have slowed significantly over the last several days. They’re going up by 1 to 3% per day, as opposed to there was a stretch there where it was going up 10% to 20% per day.
There now is mandatory masking across the state. I do see that that is being enforced, where it clearly was not before. I was at a gas station where I saw a patron thrown out of the gas station for not wearing their mask. So, at least for the time being, people seem to be taking it much more seriously than two to four weeks ago.
What about IL-6 blockers? Are you using that?
RM: Early on, we used a lot of tocilizumab, but as the data subsequently has not been stellar, we have moved in other directions favoring remdesivir-based trials. We are planning the participate in the ACTIV1 anti-inflammatory agent-focused trial.
Are you able to continue to see cancer patients that need to be seen?
RM: Yes. Treating cancer patients and keeping them safe has been a key priority for us. We never really changed that.
So, mandatory screening of staff and patients, COVID testing for all patients on cycle one, day one, for infusion therapies and radiation therapy. With that, we’ve been able to continue to be treating our patients.
We do not feel that there has been a transmission that we are aware of that has occurred in the context of patient care at the cancer center.
A lot of cancer hospitals stopped seeing cancer patients for basically a quarter of the year. Presumably, you did too. But this time you’re not stopping. Your cancer care continues, surgeries and so forth.
RM: One, we clearly pivoted to have telehealth visits. Those visits, where that was appropriate, someone was not getting infusion or radiation. It was a follow-up visit. It was a survivorship visit. It was a second opinion. That’s continued unchanged throughout.
So, we never stopped seeing cancer patients, but we clearly tried to be very mindful in terms of the number of patients that were being seen, keeping them socially distanced, and things of that nature.
The elective surgical procedures have, again, been put on hold by our governor to preserve hospital space. Although, primary resection of cancer continues to be clearly a crucial one that is not elective.
My biggest concern in terms of the impact for cancer patients is really a likely delay in diagnosis by individuals delaying cancer screening, colonoscopy, mammography, etc., or people have had symptoms that are indicative of cancer, but have not been going to the doctor.
So, night sweats, unexpected weight loss, melanoma, or passing blood. All these sorts of things, a lump in the breast. All these things that normally would have triggered a diagnosis of cancer are being delayed.
So, I’m very concerned about later stages of presentations, and very much concur with Ned Sharpless’s concern that we’re going to see an increase in cancer-related morbidity and mortality from delayed diagnosis due to the impact of COVID.
Is there anything else you have learned, either clinically or in terms of management, that’s now helping you? Is there a benefit from going through the first spike?
RM: I do think cancer patients have continued to try to keep themselves socially distant. So, I can’t say that we have seen necessarily a corresponding spike, in terms of our cancer patients becoming sick with COVID, even though we’ve seen more of a community spike. So, I do think older patients and cancer patients have been more mindful.
I do think the inpatient coordination has continued to improve throughout this process. There clearly is much more PPE and much more awareness as to what is the role of a surgical mask versus an N95, which procedures are problematic versus which are not. The improvement in the medicines that we’ve used, I think, is impactful.
Although, there clearly is a ways to go. I do think there has been tremendous improvement in coordination. So, although we’ve seen this spike, I’ve seen the coordination within our city really be outstanding.
Even with this spike, I think there’s been more efficiency in discharging non-cancer patients as appropriate, and in managing the younger COVID patients with shorter lengths of stay to preserve hospital beds. There has been opening up of additional areas of our partner hospital and other hospitals to be able to care for patients.
There have been nurses that have been brought in early in this surge uptick, in terms of traveling nurses and others deployed from the military. San Antonio has quite a military presence, and a lot of those individuals, both personnel and capacity, are participating in the resources for the city.
So, a lot of efforts by a lot of people have helped to keep a lid on it in terms of the severity. But everyone desperately needs this surge to get well under control. Otherwise, those resources, like anything, will be maxed out, and then we will be in a difficult situation.
Is this possibly harmful to the institution financially again? Or has that been somehow managed a little bit differently?
RM: Without question, this always has a negative impact on finances. It’s clearly not the primary concern, but that’s nevertheless incredibly relevant.
Cancellation of normal aspects of care, or elective procedures, or other things that are an important part of our health care economy, clearly is difficult.
We have been fortunate that I think our institution has been very well led, and, certainly, we have had strong support from The University of Texas System, and the state, and others, and have received some support through the CARES Act and other things. There clearly is an impact. It has not been catastrophic, but it’s certainly something we’re watching with tremendous caution and trying to be as mindful of that as possible.
Is there going to be a third spike, and a fourth, and a fifth?
RM: I fear that this is going to be somewhat the new normal in terms of up-and-down until we probably have an effective and well-distributed vaccine.
So, my understanding is that just the normal dynamics would predict a fall surge, and having heard direct comments from Dr. Fauci at our cancer center directors meeting last week, I think we’re still really in the first surge. This is still an echo of the first surge, and not really a second surge.
I do think we’re all going to battle this up-and-down, including areas that now have seen a decrease in cases. I fear that they will subsequently see an increase in cases for the same reason. People get exhausted by the social distancing and the masking and the other measures. It’s difficult to maintain that discipline.
Well, we do know now that masks work.
RM: Without question. I think if everyone wears their mask in all of those public situations, that clearly will help significantly. I don’t think that brings our cases down to zero. There’s probably just too much virus out there.
But without question, the social distancing, as well as being appropriately prudent with activities will be key. Clearly, large non-socially distanced gatherings are just not a luxury that any of us can have at the time being.
It’s a question of how Americans can adjust to this. Is there anything we’ve missed? Anything that you would like to add?
RM: I would say that the sharing of knowledge between medical centers and much more of the grassroots aspect of our medical system has been incredibly helpful and impactful. I think the NIH and the NCI have been incredibly helpful and supportive of cancer centers.
Clearly, the National Institute of Allergy and Infectious Diseases has been probably one of the most useful voices during this process. I’d say that there has been a lot about the medical system that we can be proud of. I would also certainly compliment you. I think The Cancer Letter has been a tremendous resource for our community to share challenges and best practices.
Well, thanks again for talking with me.