Borghaei Shares Long-Term Implications of COVID-19 on Cancer Care

Hossein Borghaei, DO, MS

The COVID-19 pandemic has caused many institutions to transition to telemedicine to provide care for patients with cancer, a practice that may continue long after the pandemic is over, according to Hossein Borghaei, DO, MS.

Looking to the future with clinical trials, some required visits for patients are simply protocol. If a patient is not exhibiting any worrying symptoms and is comfortable with a video appointment with their doctor, they should be able to meet virtually, said Borghaei. Doing so would save many patients a long drive to the clinic.

“[After this pandemic], we might have less face-to-face time with a patient in an office setting. If a patient is doing well, we can monitor laboratories remotely, and speak with them to ensure they are symptom free,” said Borghaei. “In doing that, we might be able to reduce some of those face-to-face visits and rely on telemedicine instead. I feel this [shift] would be absolutely appropriate and good.”

This pandemic has also inspired medical institutions to develop policies that will better prepare their staff for the next time an unprecedented disaster strikes.

“As with any other disaster that has happened, we are going to learn from this and become [stronger because of it],” said Borghaei. “Through this uncertainty and fear, and by navigating through these problems, we are going to become a better healthcare system. Moving forward, we will be able to take care of any kind of emergency that happens.”

In an interview with OncLive, Borghaei, chief of Thoracic Medical Oncology, professor in the Department of Hematology/Oncology, co-director of the Immune Monitoring Facility, and Gloria and Edmund M. Dunn Chair in Thoracic Oncology at Fox Chase Cancer Center, discussed the impact of COVID-19 on clinical practice and projected how the virus will change practice for the better in the long term.

OncLive: What efforts are you making to address any disruptions in care caused by COVID-19?

Borghaei: Our institution has been very proactive with this. Like many other institutions, we have been discussing the role of telemedicine in the care of our patients [for some time], but that became an emergency with this pandemic. We have, as an institution, decided to conduct many visits in a virtual setting using telemedicine. My preference is to use video conferencing to be able to see my patients and have that level of interaction. Phone calls are sometimes appropriate, and they are good in the absence of anything else.

[Telemedicine can be used for] patients who are on long-term follow-up, like those who have had surgery or adjuvant chemotherapy and they're doing well. If it is possible, the patient can get a CT scan locally so that they don’t need to go to any crowded areas, we can review the CT, and then have a telemedicine discussion reviewing the results of the scan. However, some patients still need to be seen [in person] so that we can manage any potential issues that they might have. New patients who have not been treated and require a more extensive discussion about options are still seen face-to-face with appropriate precautionary measures in place.

Our routines have been disrupted and have changed very rapidly. We still are evaluating which patients should come in and which patients are eligible for telemedicine discussions. The overall goal is to reduce the crowdedness of a waiting area and reduce the amount of interactions as much as possible. The interesting question is, "What is going to happen once the pandemic is under control and we're not dealing with this? Are we going to go back to our more face-to-face discussions or are we going to proceed with telemedicine?"

To a great extent, we are going to have to get feedback from our patients. Are they comfortable with telemedicine? Are they more comfortable with coming in person? Many patients like to review their CT images in person. How is all of that going to change? We need feedback from our patients to tell us what was good, what was not good, and we'll decide what to do from there.

Were you using telemedicine prior to the pandemic?

I wasn't using telemedicine before; this is a brave new world for all of us. My experience with this is not that extensive; it takes a bit of getting used to. I must admit that I don't feel 100% comfortable with it yet; however, I'm looking for some feedback from the patients to see how they feel about it. We all understand we have to do this for now because there is no other safer way. However, like with any new technology, we are all going to learn the best practices. Who is the best patient population for the telemedicine type of an approach? What scenarios and what conditions [are appropriate for telemedicine]? It’s just very new.

We have colleagues around the country who have been doing [telemedicine] longer than many of us. Having our colleagues provide [us with] some guidance [or feedback] as to what they found to be working for their patient population in terms of best practices would be helpful. I’m sure we’ll see some of this is in the next few weeks. Already, we are getting guidelines from professional [medical] organizations trying to help us cope with all the new challenges we are facing.

How are you working to avoid treatment delays in your patients? What kind of treatment modifications are you making in light of COVID-19?

We are definitely seeing some modifications. The overarching issue is: If a patient needs treatment, we are going to treat the patient; [we don’t want to] delay treatment. That being said, modifications may occur on a case-by-case basis. For instance, we might do a little more neoadjuvant therapy as opposed to concurrent chemoradiation, especially if a patient is not comfortable or unable to come [to the cancer center] on a daily basis for radiation. Those are the kinds of issues that we've discussed with our colleagues around the country and internally at our own institution. We’re working on determining how to streamline the care of these patients.

We are doing everything we can to not delay treatment for a patient who absolutely needs it. If it is absolutely necessary to have surgery, we discuss it with our surgical colleagues. We have to be selective and careful who we take to the operating room. If someone needs adjuvant chemotherapy, can we delay that a little bit longer? Some data suggest that you can delay adjuvant chemotherapy to some extent. However, if someone absolutely needs this therapy, then it becomes a risk—benefit discussion. The overarching issue is that we’re going to have to manage both conditions and a patient who needs treatment will get the appropriate treatment with the caveat that, on a case-by-case basis, there might be minor adjustments in the treatment and what we do immediately versus what we're going to do next.

There is a lot of discussion regarding immunotherapy because there is a possibility of immunotherapy exacerbating the inflammatory response. To me, the data are not all that clear. There has been discussion about extending the period in between administering immunotherapy. From a perspective of reducing the number of visits, that makes a lot of sense. Biologically, these drugs have really long half-lives. I'm not sure that missing 1 or 2 doses is going to be all that harmful to the patient or do anything significantly in terms of potential concurrent infection with COVID-19. These are areas where more data are going to become available based on the experience of our European and Asian colleagues. We are all trying to learn from each other regarding what the best approach is.

Do you anticipate any long-term implications of the pandemic?

The biggest long-term impact might be that we reduce the number of office visits. It's the same kind of issue we're facing with clinical trials. Many of our clinical trials require repeated visits and sometimes they are absolutely essential. Other times, we are [meeting patients in person] to ensure nothing is wrong without a lot of evidence that is necessarily needed. A long-term implication of this pandemic might be that we will have less face-to-face time with our patients in an office setting. [We may be able to convert some of these appointments to virtual meetings].

Additionally, we are all going to have this sense that we have to be better prepared for the next virus or the next situation that arises. This provides us with an opportunity to think about what we're doing right and what we're not doing right and plan for other potential issues that might come up as a nation, as an institution, and individually as a physician.

Could you highlight some of the preventive, diagnostic, and therapeutic research efforts being made with regard to the virus?

The attempts to make a [COVID-19] vaccine and the new testing [method] that shows results within a few minutes are [both] important [efforts]. In terms of treatment, the one that I've been interested in exploring the idea of using antibodies from patients who survived and managed to get over the infection to see whether that has a potential therapeutic benefit. Under that category, caveats always exist. A couple of recent papers have shown that certain types of antibodies directed against a specific component of the virus might be detrimental or not quite as helpful as others. The power of the immune system becomes important here; learning how the immune system interacts with the virus in a general patient population, and a population of patients with cancer, [can inform] important treatment strategies for the future until we have an appropriate vaccine.

What is most needed to quell the COVID-19 pandemic?

Right now, social distancing has been shown to be very effective. There are multiple examples of other countries that did this effectively. We are currently missing wider and more inclusive [COVID-19] testing. If we know who is potentially carrying the virus, we might be able to do a better job with the social distancing. Assuming everyone is positive until proven otherwise is an approach that we seem to have adopted right now. Until we get this under control, social distancing and making [COVID-19] testing more available are imperative.

I am confident that we will have a vaccine [for COVID-19]. Whether we are going to have a specific treatment for this virus, I'm not sure; that is going to take a little bit longer. My hope is that we'll be able to manage the peak [of the virus]. People are going to get exposed and we know that this virus is probably going to be with us for a long time; however, if we can manage to have less people get sick from this over a longer duration of time, we can manage patients even if they need to be in an intensive care unit (ICU). The risk right now is having 100,000 people simultaneously needing treatment in the ICU when you only have 20,000 ICU beds. While we're working on the vaccine and potential new treatments, [COVID-19] testing and practicing social distancing is the best way to proceed.

What is your take-home message?

People are doing a lot [in the fight against this virus]. We hear stories about communities coming together to make masks and gowns for physicians. I saw on Twitter that in some parts of the country, people dropped off packages, food, and snacks for their physicians in hospitals or medical facilities. It's really fantastic to see this level of caring for each other.

Obviously, we are all saddened to see our colleagues getting exposed to this disease and, unfortunately, we hear in other countries that our colleagues have lost their lives as a result of this infection. That's always difficult to see, just like it is difficult to see our patients die of this. The amount of support that we have seen people give to healthcare providers all over the world has been fantastic. My hat is off to our colleagues in China, Japan, Italy, Spain, and New York, who are dealing with this pandemic head on. We should provide as much support and help as we can for all our colleagues.