POSTED: April 21, 2020

A Crash Course in Telemedicine, Insurance Delays and Postponing Treatment

Dr. Oliver Sartor, one of the leading researchers in advanced prostate cancer today, talks about stumbling through the transition to telemedicine, the introduction of rapid COVID-19 testing in cancer centers in New Orleans, and the potential impact of delayed cancer treatments. 

He is the Laborde Professor of Cancer Research in the Medicine and Urology Departments of the Tulane School of Medicine, the editor-in-chief of Clinical Genitourinary Cancer and the author of more than 400 scientific papers. 

How difficult it is for you to transition to telemedicine? How concerned are you that you're missing things because of the switch to telemedicine? 

Dr. Oliver Sartor: There are several elements to telemedicine. Our university is pushing a formal telemedicine interview, which involves our electronic medical record. It's billable as a normal visit, but it involves interfacing the patient on electronic systems that many of the patients are not familiar with, or we have bad connections. On a recent telemedicine visit, we weren't able to execute due to his poor internet connection. There's a certain amount of reality that needs to be accepted about patients' technological capabilities, especially when dealing with the older patient population that is typical for prostate cancer.

Everybody has a cell phone, but not everybody has a good WiFi connection. Some of these systems are dependent on WiFi. I've been doing a lot of phone calls, and you can get a lot done on a phone call, but there's a lot that you cannot ascertain.

Prostate cancer patients have urgencies too, and I was about jump out of my skin earlier today because I haven't been able to get pre-certification from the insurance company for a patient who needs urgent chemotherapy. He has neuroendocrine hepatic metastases, and his prostate cancer has gone from not so bad to terrible. I urgently need to get him platinum-based chemo. Trying to get responses out of the insurance company has been frustrating.

Because they're overwhelmed with other matters?

Dr. Sartor: I can't tell why they're slow to respond. It may be because they're focused on the viral problems. I'm sure they're getting hundreds of requests related to the virus. But the rest of the world has not stopped moving. We still have urgent matters that arise in cancer, just like we do on any other day, but now it's harder to get the machinery to move forward. So that creates its own set of issues.

What's your concern going forward that a lot of the delays we're seeing will impact men's chances of survival?

Dr. Sartor: I'm worried that we're delivering suboptimal care. Trying to get a radical prostatectomy done right now is impossible. The New Orleans area has over a million people. We're not sitting in a major metropolitan city, like Los Angeles, New York, or San Francisco, but we cannot get a radical prostatectomy done now. That's not considered to be an urgent operation. We have patients with Gleason 8, Gleason 9 cancers that we would ordinarily prioritize for the radical prostatectomy, and we can't get them on the schedule.

Some of these are diverting over to hormonal therapy because we can give hormones to kind of stop things. But in general, I don't like to give hormonal therapy prior to surgery. It obscures the Gleason score. It can obscure the margin status. The pathology reports are not as reliable. Your postoperative prostate-specific antigens (PSAs) are changed. We rely on our pathology reports and our postoperative PSAs to provide guidance. But we're being caught in a situation where we are not able to implement the ordinary cancer care that we believe is optimal because the operating rooms are shot except for true emergencies.

When everything opens back up, is there likely to be some sort of bottle necking?

Dr. Sartor: I spoke to our Chairman of Neurology, who is a well-recognized neurology cancer surgeon, and he has 38 cases on his docket. When that opens back up, he's going to have to prioritize. He's getting tremendous pressure. Our patients are calling him to ask, "When can I get my surgery done?" It's an awkward scenario.

It's not clear when things are going to open up. It changes week to week because these problems are increasing in their magnitude. The delay is increasing the number of patients. The delays in terms of getting patients on the schedule are real. These are not new, but they're escalating in terms of their impact since they're affecting more and more patients.

This week, we have two interesting developments. Number one is we now have the rapid viral testing in our cancer center. We have the 15-minute test, which gives a positive result in five minutes and a negative result in 15. It's based on the Abbott rapid technology, almost like a rapid flu type test.

We implemented testing in our cancer center this week with a priority on hematologic malignancies, since those patients are almost all immunosuppressed, and patients on active chemotherapy. All asymptomatic patients tested negative so far, which is good news. If somebody is symptomatic, we send them in to the separate pathway, and if somebody comes in with a fever, we don't even allow them in the cancer center.

The two states that have the most testing per capita of any state are New York and Louisiana. We have four medical schools in the state, which has helped since most academic centers have the resources to get tests up and going, more so than some of the smaller community hospitals.

It's not clear if the antiserum test or the antibody test is coming, but we have fair testing capacity. We have three different methodologies. We have the Centers for Disease Control (CDC) Polymerase Chain Reaction (PCR) methodology, the Roche technology, which is high throughput, and the Abbott technology for rapid turnaround.

How do you determine which one to use?

Dr. Sartor: We're using the rapid one in the cancer center. But for the hospital patients, they use the high throughput machine. Before, people were waiting days to get their test results back, so the rapid testing machines have been helpful.

We're also instituting a saliva testing since it's easier to spit in a cup than to do the nasal swab. That will help us to get testing done in an efficient manner. The nasal swab can induce coughing and sneezing, which requires you have to have people in the protective gear. Now, we have a frontline nurse with goggles and a mask to protect the personnel.

It may take a while because the saliva testing will have to be an Institutional Review Board (IRB) approved protocol.

My patients are incredibly compliant about staying at home. I cannot pry some of these guys out of the house. I tell them to come in and their life depends on it, and they say, "Hell no, I'm staying here. You come to me." I'm not allowed in their house either.

It's a dramatic downturn in the hospital admissions now. University Medical Center had the most, 165 COVID-19 positive or suspected patients in the hospital at the peak, and they're now down to 40. They never even came close to running out of ventilators.

That was the biggest concern, right?

Dr. Sartor: It was a huge concern. They had to open up additional ICU beds. The hospital did a great job in terms of expanding the resources necessary to take care of these patients. It was also gratifying to see individuals volunteering to be a part of the services. There was a strong and generous response from the medical community.

We have bent the curve here in New Orleans, which was the original goal. New York is worse. New Orleans doesn't have that same density. But one of the other factors here is poverty, which reduces people's capability for social distancing. It's easier to maintain distancing when you have more resources.

The state's been tracking our African-American population, which is around 30% of the state, but about 70% of the fatalities have been African-American.

Do you think that's because of socioeconomic factors?

 Dr. Sartor: It could be underlying comorbidities. Some of the clear risk factors for mortality are diabetes, obesity, and kidney failure.

There are differences in comorbidities in African-American populations relative to Caucasians, not just in New Orleans, but in many cities across the country. That may be an underlying thing, but it could be socioeconomic. It's probably a combination.

Any comments or advice for men this week?

Dr. Sartor: I still have some persistent optimism since social distancing does seem to make a difference. It's going to be a tremendous challenge to determine how best to open up the country. We're flattening the curve in places like New Orleans. We got a fast start because of the number of visitors that we host.

But the good news is that we have turned the curve now. It's too early to open back up. I would love to see better, more widespread testing and institute contact tracing. Massachusetts was trying to initiate a contact testing program. Who did you contact? Who were you with? And trace it down like you would in tuberculosis, which has been a tried and true method. But the number of cases has overwhelmed any possibility of contact tracing.

It's going to be awhile before we can go back to normal. The issue is that nobody's immune to COVID-19 unless they have it. With influenza, you have some degree of immunity from prior exposures and different strains. But with this, everybody is susceptible to it. And you could be an asymptomatic carrier. There's no doubt in my mind that there are super spreaders. Because of the aerosolization of the virus, even six feet of space may not be enough in certain cases.

The early 80s outbreak of AIDS is the only thing that resembles this. In 1982, I was a senior medical student. It was scary at first because you didn't know how it was transmitted. The nurses would refuse to take care of patients. People were hysterical, even more hysterical than they are now because they didn't know how it spread.

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