POSTED: May 01, 2020

Dr. Susan Slovin: End of Care Discussions With Patients During The COVID-19 Pandemic

Dr. Susan Slovin, MD, PhD, is a medical oncologist specializing in prostate cancer immunology at Memorial Sloan Kettering Cancer Center in New York City. 

Prostatepedia spoke with her recently about caring for her prostate cancer patients with COVID-19.

 How are things going for you this week?

It's my clinic day, so we have a lot of video and teleconferences. They're exhausting. There's nothing like a physical exam. And we are now addressing, as discussed last week, goals of care with each patient because of the COVID-19 setting. We want to make sure that people understand what will happen if they sustain any sort of respiratory dysfunction if infected with COVID-19, including the risks.

Some of these patients have advanced prostate cancer. They're aware that with chest compressions or being on a ventilator, they could have complications that may prevent them from safely coming off the ventilator, or they could die of other issues that have nothing to do with COVID-19. But everybody wants to be on a ventilator, even understanding the risks, the successes, and the lack of success depending on the circumstances.

Every patient has been so amenable to being in contact, either by telephone or video. They express their gratitude with each visit that they feel linked in and valued. They feel as if we're doing everything to make sure they're safe. It's a nice feeling considering the way the world is right now.

 What is the feeling at the hospital and in your clinic?

Dr. Susan Slovin: We are seeing a lot of clinical trials for COVID-19 patients. They are being treated with different drugs or in different combinations. The infectious disease and the critical care physicians are heavily involved with generating clinical trials to get people treated in the most scientific and clinically safe manner possible. It's a credit to all our colleagues that they are going full court press in dealing with our patients, both in the unit and already on a ventilator or in the unit for observation with evidence of decompensation.

Some patients who are coming into the clinic need their chemotherapy treatments. They are extremely brave about coming in. None of them have said, "I'm too afraid to walk out of the house." We've made sure that we keep their counts up since, with chemotherapy, blood counts can go down. We're making sure they have either Onpro or Neulasta (pegfilgrastim) to keep their counts up and do whatever we can to maximize their immune system to keep them safe. Everybody has done well. It's rare that anybody has an issue. The only challenges are those patients who have pain issues.

In New York, the curve is going down, and we have cautious optimism. New York is locked down until June. From my own standpoint, we're not going to be out of the woods until August.

 What do you think about the fear that once life goes back to normal, we'll see a resurgence in cases?

Dr. Susan Slovin: It's a possibility. We've seen that with other diseases, particularly with other kinds of influenza type illnesses, and some of the other coronaviruses. We know that in some cases, there is a recrudescence. People do well, and two weeks later they feel ill. We don't have a handle on the biology of this virus. We don't know whether this disease mutates in each patient, leading to each patient having a different response. You can't predict it. The administration is doing everything it can to curtail it. If social isolation is what it needs to get a handle on behavior and get a sense of what's going on with the convalescent serum and the serologic testing, then they're doing everything they possibly can.

People have to understand that this is a pandemic. If this were smallpox, we'd be saying the same thing. But when people are safe at home, they don't appreciate what's going on. If you're on the front lines, you have an appreciation. 

You mentioned that there are many clinical trials looking at patients with COVID-19. That's fast-tracked from the normal clinical trial process, correct?

Dr. Susan Slovin: Not necessarily. If there is something that is a major problem, clinical trials get a drug to the patient faster. We have no data to suggest that any of the current recommendations will be standard of care. They're not at the moment. Attempts are being made to use those drugs and related drugs in different clinical settings to see if these drugs are working. Giving them haphazardly and not checking blood or viral load doesn't help you. Because this is a pandemic, efforts are being made to use these drugs in a more intelligent way. We're not just saying, "Go ahead and take it." We want to do it in a structured environment.

For any disease that it has an unmet need, whether it's a pediatric illness or a rare malignancy, we try to expedite clinical trials. We don't hold one over the other. The red tape sometimes encumbers our ability to institute the trial sooner rather than later. It's improved dramatically, so we're optimistic.

 

 

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