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.
Week after week, Giuseppe Curigliano is waiting to see the first signs of a slowdown in Italy’s cases of COVID-19, and week after week, he is disappointed.
We’ve been reaching out to Curigliano regularly:
What to expect: Oncology’s response to coronavirus in Italy (The Cancer Letter, March 11).
Curigliano: “I don’t want to see more people dying” (The Cancer Letter, March 20).
“The curve is quite clear that we are not in the condition to say it’s flattened, maybe it’s going to be flattened. I believe, by the weekend, maybe, we will have those data,” Curigliano, associate professor of medical oncology at University of Milano, and head of the Division of Early Drug Development at the European Institute of Oncology, said to The Cancer Letter. “I hope to have a normal situation by the end of May, realistically.”
Curigliano spoke with Alexandria Carolan, a reporter with The Cancer Letter.
Alex will keep checking in.
Alex Carolan: How have you been? How are things in Milan?
Giuseppe Curigliano: We are still not in the condition to say that we’ve flattened the curve. I can share my screen and I can show to you the data of today,
Sure.
GC: Just to show what is going on in Italy, we have 80,539 positive patients, and the total number of people who died are 8,165 as of March 26. If you look here, the curve is quite clear that we are not in the condition to say it’s flattened, maybe it’s going to be flattened. I believe, by the weekend, maybe, we will have those data.
The most important information that I can share with you, is that up to today, 44 medical doctors died due to COVID infection. Many of them are family doctors—44. Then, we have 6,205 medical doctors who are positive for coronavirus. It means that some of the people infected are health professionals. It’s important to reinforce the message that we should protect ourselves. In the hospital, we are more protected, but family doctors, maybe, are not protected.
In the last week, we have the data of cancer mortality rate—those are the official data.
The median age, finally, of our population was 70 years old, or older, of the people who died in Italy. Twenty percent of them had active cancer. It means that out of the people who died, 20% of them are with active cancer, or a new diagnosis of cancer, or a cancer under treatment with any type of therapy.
Now, we are going to look into the case of those data. Important information is that 70% of Italian patients who died are men, and just 30% are women. In our country, we have less women patients with COVID infection. It is important information, I believe. We don’t know why.
Maybe women in Italy underwent more vaccination in the past, because when a woman should plan a pregnancy, usually they test for all the type of infection. If they have no protection for a specific agent, they receive a vaccination. This can be an explanation. We don’t know. But for sure, we have less women infected. Really, we expect, the 70% is completely different.
So, 20% of those who have died of COVID in Italy were patients with cancer?
GC: With cancer, yes. These are confirmed data. Yes.
You said last week that you were treating three patients with cancer who also had COVID. Is this still the case?
GC: No, we have more patients now.
Last week, there were three. Now, in my hospital, we have eight patients with COVID.
You should consider that in my center, what we are doing, is having two checkpoints at the main entrance. The first one, is in order to understand if a patient has fever or not, and an evaluation of the anamnesis.
And, then there is a second one internally, where we complete a medical checkpoint. We are trying to reduce the number of infected people.
But, all the eight people that are positive entered the hospital without fever. They started treatment, and the day after, or two days after, they developed fever. We tested, and they weren’t positive for COVID-19.
It seems that we may have patients with no symptoms that enter the hospital. Maybe they were positive, and then they developed symptoms after we started treatment. This is more complex, because if they received surgery, or they received the chemotherapy, then you have a patient with complications of COVID infection after receiving an active treatment.
What happens in that case? How do you treat them?
GC: Well, in that case, we isolate them. We intensified the monitoring, because this is very important. If fever is more than 39 degrees, they should be hospitalized. But if they have fever 37, 38, and they don’t have or experience symptoms, you dismiss them, because there is the risk of infecting other patients, and we do close monitoring at home.
We’ve dedicated now, an area of the hospital for COVID patients—it is a limited area—six beds with trained staff. We have a trained nurse staff and trained doctor staff. Until now, this hospital had just one patient utilize it. This is a head-and-neck patient who received a major surgery, and who developed the symptomatic COVID-19 syndrome—and actually he’s still hospitalized, is not intubated, and it’s going well.
How many of your own patients have COVID?
GC: Now there are four. Four of my patients.
Given that patients with COVID-19 were able to enter the hospital despite checkpoints—because they didn’t have symptoms yet—are you changing how this system works? I mean, I know it’s complicated.
GC: What we are doing now is restricting access to the hospital for relatives. If you open the hospital during the visiting hours to relatives who potentially are infected, this may impact on your patients. No relatives can enter the hospital, no vendors—the hospital is open just for patients who should receive treatment.
This, psychologically, is quite stressful for patients, because, if you think about patients who are stressed because they have to receive a major surgery—and no relative can come in the hospital.
But, we have to protect them. They are not complaining. They understand, and they use much more FaceTime to communicate with their relatives. It’s the only way to communicate.
One other thing I’d like to discuss is the app you talked about last week, on how you’re monitoring patients through that. Do you expect to use this app after the COVID-19 pandemic has passed? How will this change how you treat your patients?
GC: I believe that remote monitoring with telemedicine or support of technology will be essential in the future.
Many visits can be really avoided. You can limit the access to the hospital, if you have to monitor toxicities that are expected, with drugs that you know.
If you know very well the safety profile of one agent, you should not ask the patient to come here every week to monitor toxicity. You can really use those apps or tele-monitoring to give more comfort to the patient, because accessing frequently to a hospital can be stressful for the patients.
I believe this will affect the way we treat them, and the standard of care of the patients.
I was discussing it this morning with my physician-in-chief, and he said, “Okay, now you are saying that you will do this- this-and-this after the COVID infection, but I am quite sure that in the future, everything will come back like in the past, because we never learn by the experience of the past stuff.”
I hope he’s mistaken, but I will try to change something after this pandemic, because we need change overall in the world. Something should change.
What else do you think will change? What will be different?
GC: This will change the way we do meetings. We organize every year meetings with 40,000 to 50,000 people just to do a discussion, to see the data live. But, I believe that maybe one meeting per year is enough for any specialties— and many other cancer meetings can be delivered with streaming.
If you have some old meetings that are disease-oriented, maybe you don’t need to do a usual thing. You can also go by streaming. I believe meetings are important for networking, but in terms of access to education, you can really do this by web.
It seems that we may have patients with no symptoms that enter the hospital. Maybe they were positive, and then they developed symptoms after we started treatment. This is more complex, because if they received surgery, or they received the chemotherapy, then you have a patient with complications of COVID infection after receiving an active treatment.
Also, medical education should change. I work in the University of Milano, and after the locking-down, you cannot take lectures directly with students. We use streaming and Zoom meetings, exactly like you. All the students are connected, and they raise their hand or they ask questions—exactly the same thing. I know it’s not exactly the same as doing training on the patient, but maybe for some lectures, you can deliver lectures online.
This will change. We should change this. This will impact patient care—implementing telemedicine—but also education and training—implementing streaming meetings. And when you have to do advisory boards or to discuss a steering committee, you don’t need to do face-to-face meetings. You can really do everything by streaming, all these small meetings.
In the past, I was a frequent flyer. Two intercontinental flights per month, something like five or six flights in Europe, and then many flights to Italy. Now, I stopped any type of flights, and we did exactly the same meetings. So, we meet for nothing. With the exception of meetings that are larger—all the other meetings, we did them by streaming. It’s very easy to do this.
As you know, you cannot bring 40,000 people together with the risk of any pandemics. We have to expect every three or five years the potential of a new virus spreading. We have to be ready first. We have to lock down after the first infection, or infected people. And we also have to think of a way to revise these huge meetings. It’s very important, I believe, to think about this—because, maybe, in the future, we will save a lot of money that can be reinvested. There are activities, web activities.
Do you think that COVID-19 has taught us how to respond to pandemics better in the future?
GC: Yes, absolutely. I remember with SARS and MERS, if you remember it, you were very young. For SARS, AACR in Toronto was canceled.
But during SARS, a few thousands of people died. And I don’t remember a general lockdown outside the Middle East. In the Middle East, there was a general lockdown, but in Europe, in the United States, we did not make that decision.
But now, with COVID-19, that was much more dangerous in respect to SARS. And, looking at the data on mortality, all around the world, people—in New York City—we have to learn from these experiences that we have to be prepared for another potential infection, and we have to be trained in those sort of things and all their potential infections.
We need to reserve part of our budget, to be an emergency plan. So, my suggestion is, every year, any hospital, also most hospitals, should have an emergency plan in case of a potential infection. And, so as we do training for fires, or for something like this, we also have to do training for a potential pandemic. This is my important message—any hospital.
In the U.S., a lot of hospital systems are about to be very overwhelmed. One thing you mentioned earlier was how a lot of family medicine physicians are becoming infected in Italy.
GC: 6,205 health professionals, with 44 doctors who died, many of them familty doctors but also anesthesiologists, and infectious disease doctors. It’s a lot.
In the United States, there’s a shortage of personal protective equipment, and a lot of doctors are reusing them, or they’re not able to access them, and their health care teams aren’t able to access them. Was this the case at all in Italy, was this a problem?
GC: No, because we never experienced a shortage in our country, because since the beginning, we tried to buy, as a country, all available PPE across the world. In India, in China, in Turkey—we asked them for PPE. Despite The Cancer Letter, a few weeks ago, saying to be prepared.
The first thing to do in the United States, was to be prepared in terms of ventilators and personal protective equipment. I know many colleagues told us that they don’t have personal protective equipment.
What we did in Italy was build the new factories. There was no factory in Italy producing masks, no factory in Italy! It’s impressive.
We tried to build the same factories for using masks. It’s important in the United States, to open, and to give facilities to factories that would like to produce masks, and all this type of protective equipment at a very low cost—so no one is interested in producing them.
That’s why we imported from China and India. We imported all the masks from China and India, paying them a lot of money—because, now, the cost is very high.
In the U.S., they’re trying to get the federal government to take action to have factories in the U.S. produce what is needed.
GC: Exactly. What we did in Italy. You need at least one week, but you can do this. It’s like a war. This is a war economy. When you have to prioritize the factories who have to produce something you need, this is a war economy.
I’d like to bring this back to cancer patients. You talked about clinical trial disruptions last week. What are the disruptions, exactly? How is this affecting your own research?
GC: In the last two weeks, we generated more violations than in the last six months. Because, according to protocol rules, you should do CT scans, blood tests, exactly within the window of time that we did not respect. And, we did not respect this, because many patients have no access to hospitals. Many patients received scans at home, many patients received blood tests at home. Many patients missed visits that are required for the protocols.
And, we delayed these CT scans and blood tests. We delivered the drugs with specific delivery systems at home. For any one of these actions, that was a good action for the patients—it was a bad action for the protocol.
We generated protocol violations. And though the sponsors tried to face this emergency, some meeting protocol amendments, we generated violations now that, in a few weeks, will be no longer be violations, but will be new protocol rules.
There will be permission to do a CT scan at home, blood tests at home, to deliver the drugs at home.
Another important point was the use of enrollment. We had many patients coming to the hospital, and less patients enrolled in protocols, because we have to take care of the safety, so we did much more standard of care, and less enrollment. Many companies decided all over the world to stop accrual. Many big companies sent the letter to stop their accrual. This affected a lot of clinical trials.
Right. Do you think that this will affect cancer drug approvals in the future?
GC: Yes, I believe yes. Because if you have a registration trial for which you need to reach a target sample, if you stop for several weeks the accrual this will impact the delivery of the data. You will have less patients enrolled, a delay in the completion of the trial, a delay in the submission of the dossier to the FDA, and a delayed approval of a potential new agent. This is my impression.
How far into the future do you think that we’ll see these disruptions?
GC: I believe, at least in my account, I hope the companies will consider this country by country.
I hope in Italy, to be realistic, by the end of May, to have exactly the same situation of the Wuhan Region, China. In this weekend, they will reopen everything. I expect in my country to have flattened the curve by the middle of April, and then have a decrease by the end of April, and the complete reopening by the beginning of May or maybe mid-May.
In my country, I hope to have a normal situation by the end of May, realistically. We have to consider a delay of two weeks for France, Spain, and Germany, and the delay of three, four weeks for the United States. So, everything will be normal again across the Western seaboard, maybe for the end of July, realistically.
And not Easter, as Donald Trump said. Because he said that after Easter, everything will be reopened, and I don’t think so.
I think a lot of people in the U.S. agree. You expect to see that curve in Italy flatten in Italy by mid-April, now?
GC: I hope that if we respect the social isolation and containment measures, I hope that for mid-April, we will have a decrease of infected people, exactly. Not a flatten of the curve, but a decrease. The flatten of the curve, I expect for mid-April.
Are you still feeling positive, going forward?
GC: I feel positive, because my family until now is safe. Because many friends of mine that are doctors are safe. I know of many colleagues who are medical oncologists that are in intensive care units. I know them, so I am worried about those doctors that have been affected and have serious complications.
I really hope that there would be much more protection for family doctors, because the 44 doctors who died, are all family doctors—doctors who visit with patients with no protection, I assume, because they believed this was flu, and finally died due to complications of COVID-19.
Could you describe what a family doctor is?
GC: In Italy, we have a national health system for any single community, any single village or small town, has one to two family doctors that take care of basic medicine. All the family can go there to report the symptoms or any problem.
They decide if they give medication, and taking care of them at home or they can decide to send the patient to a specialist in a large hospital. You have to imagine that in the last six weeks, the first doctor that took care of all COVID patients on the frontline, was a family doctor. They were over there with something that was similar to flu symptoms in the beginning of January, and the family doctors had contact with them. The doctors there that are dying today have been infected three or four weeks ago, and they were not aware about COVID-19.
They have been at the front line. And actually, all the symptomatic patients at home, who have not been hospitalized, in a small town or in a small community, they are cured by the family doctors. They are the doctors they call—if they have an emergency, they go to their home. In Milano, we have thousands of family doctors, it’s a huge city with millions of people.
Are family doctors in Milan disproportionately affected?
GC: Now we are trying to do more training for them and more education. Actually, Regione Lombardia is giving them personal protection equipment. Every week, they have to go in the central hospital to take personal protective equipment. We are reorganizing the network for them.
Do you have anything else you’d like to add? General advice?
GC: We expect from the United States of America, much more investment of research, and much more investment on delivering new clinical trials to take care of COVID patients. My request is to give a lot of interest to this COVID infection in order also to find something to cure those patients who can be cured. A huge investment from this.
You have to take the leadership on this. OK?
Agreed. Thank you so much, Giuseppe.
GC: Thank you to you.
Let’s touch base again next week.
