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Strategies for Optimizing Timeliness of Diagnosis ...
Strategies for Optimizing Timeliness of Diagnosis
Strategies for Optimizing Timeliness of Diagnosis
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Good evening, everyone. I'm Eric edel and on behalf of chest and our industry sponsors from AstraZeneca genetech and Berkshire condom. I want to welcome you all to our fifth installment of webinars that are on primarily the personalized online training for lung cancer management. As I said, this is our fifth and a series and I'm very excited tonight that we have three expert panelists with us that are going to share their experience on strategies for optimizing optimizing the timing list of diagnosis treatment and with lung cancer during the global crisis. We're hopeful that through this webinar, you'll achieve the learning objectives that we have listed below. our panelists represent pulmonologist medical oncologist and Thoracic Surgeons who are experts in the managing management of lung cancer. You can see the locations of each one of the panelists here. I'm very excited for for us to hear each one of their presentations. the obligatory disclosures also on behalf of my co-chair Tim mcgoo welcome you once again, and I'm going to turn the program now over to Dr. Tenek. Who will give the first presentation? Okay. Well, I like to thank Dr. Adele and Dr. Magoo for the opportunity to speak on this topic. I think the last two years have been very hard on everybody and it's easy to have a lot of covid fatigue, but I think it's important to realize that you know, there's a couple reasons to to not to not forget about what's been going on. What is the, you know, there's still a large number of deaths in the country every day from covid and and I think also important as we can't we have a crystal ball. We can't see the future and we don't know when things may progress again and when all of these tools that we've gained over the last couple years we will need to utilize again in order to take care of our patients and specifically our lung cancer patients. So I'd like to start out here with a question when proper PPE is utilize for flexible bronchoscopy. What's the reported rate of covid? transmission for healthcare workers I'll let you plunder that. Okay. All right, so pretty equal spread well. Get to that a bit. So let's I wanted to base this presentation on a case the hopefully brings out some of the some of the important topics for related to timeliness of diagnosis and management of lung cancer during the pandemic and this is particular one was was pretty challenging and this is a 19 year old woman who is an excellent help until December of 2020 when she developed fever's cough and shortness of breath over a few days. She went to her local Ed. She was 12 and was positive for covid told to return home to quarantine and well her fevers improved her shortness of breath and her cough continued to get worse. She returned to the EG about a week later and auction saturation was 80% on room air respiratory status decline in the Ed and then she was on 15 leaders on breather a chest x-ray was performed. And this is what we're looking at and and for everyone in the audience who's seen a whole lot of covid by now, you'll know this is not a very typical view of covid. Pneumonia where you have complete volume loss of the left chest and white out of left heavy thorax. So we already use something something was going on and then just to bring in kind of where we were at Los Angeles at the time that she presented. So I have this red arrow pointing to kind of the day of her presentation where we had an average of about 13,000 cases per day. And then the death rate as you can see around this time is really starting to spike. So the status of the pandemic at the time of her presentation was was really pretty critical in other words some good news. We had readily available testing. We had a lot of PPE and and overall over the last several months. We gotten pretty experienced a lot more comfortable caring for patients with covid but but a lot of bad news as well or I see was full hospital was full and not accepting transfers. No ECMO circuits vaccines were not yet available. So all sorts of concerning things wondering how are we going to make this happen? How are we going to take care of this poor woman and just to show you our CT scan which was equally concerning where you can see that that left main stem Broncos is blocked off. She's got a right up her little lesion and she's got a lot of narring over bronchus intermedius and even some tracheal stenosis. So so really a very scary looking presentation. So I presented her because again she president she presents a number of challenges and especially we want to get for it. As possible. She's young. She's got a big chest wall mask we think it's malignant respiratory failure planning respiratory status. So and by the way, she's actively covid positive and at the peak of The covid Surge and at a hospital, it really did not have resources to take care of her. And of course, this is a page that comes in around 11pm on a Friday night. So this brings up, you know, how do we overcome some of the barriers to Lung Cancer Care during the pandemic and I think for us unlike the chaos during the initial surge, our institution was a bit more prepared during the second surge. We had extended ICU capacity. We're more familiar with managing covid Patients Hospital and I see protocols for present for prioritizing cancer patients. We had adequate PPE and testing was widely available at that point. so this patient was transferred to racu and I wanted to segue off into one of the questions that that we received before before the webinar, but asked us to talk about strategies to overcome delayed procedures and figure that's a relevant thing to talk about at this juncture and I think To address that question. I think the issue is what is the root cause of the delay of the procedure? And I think we know with each surge of covid. There's been different challenges with the initial surge, right? It was everything was shut down. No patients were allowed to come in for elective procedures patients were scared to death to come into the hospital that they would get covid. In later in later parts of the pandemic it was you know more recently with this more recent Wave It's been more staff because people will not terribly sick are not showing up for work because they have covid or there's issues with the supply chain. So there's all sorts of challenges. I really think you need to kind of address each of them as they come up, I think as far as space, I think it becomes a discussion with the hospital regarding where you gonna prioritize to get in, you know, in our hospital we made sure that lung cancer patients and cancer patients in general at the top of that list. Um, that goes also with prioritizing when there's minimal staff. What is the hospital gonna wear you where your patience going to be up on the line of are they going now or they gonna be at the end of the day or are they gonna get delayed? So I think it's buying from the institution as far as making sure that the cancer patients are are taking care of first. Or near the top. So so it gets get back to our patient about you know, kind of who gets a bronchosky so early on in the pandemic three societies produce guidelines for and this is all consensus based as far as who should go and win Society of advanced for advanced broncosity released a consensus statement and they divided it up into five different categories anywhere from emergent which would be a same day procedure for someone like in this patient's case who's got severe symptomatic Central Area extraction or someone with massive homoptysis or form body aspiration. That's acute all the way to elected such as doing a Baal for Mac or or doing surveillance biopsies for a transplant patient and then the chest and a abip do they combine guideline very similar again dividing patients between emergent broadcast could be urgent bronchos could be a non-urgent broadcast again. Just helping providers know kind of where their patient should go and how to Prioritize them in what level if you have someone who's got a lung Mass with lymphadenopathy, where do they go? And I think that was what's helpful. Can we shoot for around within two weeks is more reasonable. So then we know kind of how to move forward. Also in the chest abip guidelines, they gave us some summary of recommendations, but fairly basic meaning if someone's got confirmed to suspected covid. Well you want an n95 respirator or a halfer. I want a bronchoscopy is indicated to diagnose stage or characterize someone with suspected lung cancer. That is an area where there's transmission of covid. We suggest Broncos can be performed at a timely and safe manner. So no one could really tell you exactly when it was supposed to be done. But kind of get it done as soon as you possibly can and when it's safe. This is a proposal of recommendations for IP procedures during the covid-19 era and just want to touch on several of these points. You know, it's been big in our hospital and actually continues to be biggest screening. We continue to screen patients before aerosol generating procedures and have we have a very adequate Supply PPE. Well, we did not use brought disposable bronchoscopes that is a recommendation. But we did the high level disinfection on the reusable bronchoscopes and then using negative pressure rooms when you can with at least 12 Eric changes for hour initially in the pandemic, we were really trying to limit the number of Staff available. So that meant, you know, typically when you're doing a broadcast, maybe there's lots of least in our this is our facility. This one is a lot of extra patient people in the room. So we made sure we were kind of on a skeleton crew and then minimizing things that will result in aerosol generation, like avoiding atomized lidocaine for us virginity was really put us a minute minimal because we typically use Jeff ventilation and we perform broadcast urgent. to emerging conditions now how now that so now that the initial data came out and a couple years have passed and we're starting to regroup some of these questions were looking back at which is how risky is it to perform a broadcast down to covid positive patient. This is something that scared us to death or at least myself early on when we weren't sure if we were truly protected. So and then the early guidelines were based on data from the initial SARS epidemic which recommended significant restrictions and procedural volume, but we know that when proper PPE is utilize the risk of transmission to covid health care workers. It's actually very low and there's an article that I listed their published in 2021 that analyzed 12 studies included 646 patients that underwent almost a thousand broncosity and only one study reported a broncosmith to develop covid. Now, you know, is it possible something was missed of course, but I think overall you see that the number of the risk of getting covid when you're adequately protecting yourself while you're doing a broadcast is quite low. And so just to cut back to the case very quickly in this particular patient's case, you know, what was seen on the CT is what was seen on broadcast to be with obstruction of the left main stem the right upper lobe lesion the bi was narrowed down but there was kind of opening beyond the left main stem bronchus. So with a lot of work with stencing and with cauterization her post CT scan or host post extra post procedure. X-ray shows really good ventilation of the left lock so And so this reminds me to kind of go back. So when the pandemic initially started there's a group of Interventional pulmonary Physicians who started the global pandemic SARS Kobe 2 brought database. They reached out to a lot of people to try to have them record their patients. I think this was a brilliant idea to try to get more information and the ultimately in the manuscript there are 289 patients with known or suspected covid. And this was done in March to August of 2020. So really right at the beginning of the pandemic it's so what they saw in this patient population is that bronchoscopy established a diagnosis and about half of the patients and it also changed management about half of the patients whether that was new treatment or changing their location or removal of existing treatment. The other important thing is how patients tolerated bronchoscopy. So this second table looks at bronchoscopy related Adverse Events and you can see that bronchosphere related averse events occurred about five percent of patients. And then another about six percent of patients showed clinical decline within 12 hours death rate was actually surprisingly low in this group of only one patient. Did the covid outbreak impact access to lung cancer diagnosis and treatment again, this is now we're looking back and seeing how did it really impact were able to take care of patients where where were the delays and so this is a multicenter trial for Italy they compared to access the year before the pandemic and the year of the pandemic between these two years. There is about a seven percent decline in new lung cancer diagnoses that was not a statistically significant p-value but aired in that direction and that newly diagnosed lung cancer patients in 2020 were more likely to be diagnosed with stage 4 disease. But in this particular study, there was no difference in interval between symptom onset and radiologic diagnosis psychologic diagnosis for treatment. So in this day, it's pretty impressive. There was actually very there was no delay detected. Now, how about this is another study looking at the same thing from Canada and did the same thing compared to year before the pandemic in the year of the pandemic and I specifically highlight referral to diagnosis because that's oftentimes where IP steps and is that is that time frame and for them the recommended wait time they were shooting for was 30 days and interestingly enough. They actually saw that they look the percentage of patients that went from referral to diagnosis in 30 days to be 40% in 19 2019 and 48% in 2020. But what we do see is that there's a overall a big decrease in new lung cancer diagnoses about 35% So while out of those patients that presented they were taking care of people just weren't presenting for their diagnosis. So Going back to this case in this particular patient. She had had no carcinoma with an ALK translocation and she was started on targeted therapy right away. We recommended that she undergo repeat bronchosky every couple of months after discharge, but she refused due to concern that their she or more likely a family member might get covid. So So now what do we do? What are the guidelines say for something like surveillance bronchosk? If you want this situation, you know when we talk about airway stent surveillance, we're down on the Subacute SO waiting more than two weeks is fine. In patients with confirmed cob infection who recover and need a routine bronchoscopy guideline recommendations were really to base it on the severity of covid that infection and the time from symptom resolution. So for her, we could have done the procedure. She opted not to instead we did routine follow-up bronchoscopies to evaluate the stent. I'm sorry instead of routine broadcasting these we actually perform phone calls about every two to four weeks and it's because this patient did not have internet access and we were able to assess her Airway on CT. And so this brings up the last point which is telemedicine, which is I believe many of us we talking about today which is and I like this graph because it shows weeks prior to the onset of the pandemic where they proportion of visits that were telemedicine visits. We're somewhere around 15% and then within a really a couple of weeks you jumped up to 75% which I think better the name and thought that we could we could we could accomplish and for our institution. We were we had an early multidisciplinary for us Oncology Clinic. That quickly switched to a Telehealth Clinic which we have kept because we find that it allows patients who live far from the hospital to get opinions from providers and multiple Specialties all in one morning. And then we have family members. Sometimes remotely from across the country who either can't be physically present due to distance or maybe they have covid and they can't be present but they're able to participate these meetings, but I think important to remember about telemedicine and I think we've all experienced. This is that it's not always seamless right requires Broadband or high-speed internet and internet capable device and Technical technological literacy of the patient. So there's somewhere around close to 20 million Americans who don't have broadband service. So Porter remember that well tell medicine is been very helpful and opening and opening up care for patients around the country. There's a number of patients who are missed by this because of the lack of Technology. So just take own points briefly timing of bronchoski during the pandemic depends really on the urgency of the procedure. We're the hospital is with the resources and the covid president prevalence with prioritization of lung cancer evaluation consensen statements help to guide the prioritization of bronch procedures and they really helped us to know whatever else thinks when we should be doing these procedures But ultimately it comes down oftentimes to a case by case basis when you make that decision assessment follow-up patients may be limited and requires a flexible approach to minimize transition again considering telemedicine when possible Determine appropriate options to reduce patient contact and we didn't get into that too much. But when you consider Imaging when you consider liquid biopsy and we may touch on that in the future here and when performed under a proper conditions bronchoscopy and patients with covid-19 overall is a very low risk of transmission to providers. And for the last question here regarding bronchoski being patients with suspected covid, which of the following is, correct? Okay. All right. Well like to thank you panic. That was that was excellent. I do have a question. We don't have any additional questions in the bot chat box yet and I encourage the audience. If you do have any questions for any of our speakers, please put them in chat box. It's an opportunity for you to pick their brains, but I have one question as you look back at what we've been through in this pandemic and what we've learned from the standpoint of how to manage the aerosolized procedures that we're involved in. Do you anticipate will continue to do business like we're doing it now or do you think we'll go back to what we were doing before? What's what's gonna stick long term? I think that's a good question. I mean, I think you know, I've seen both right I've seen people minute they can switch back, you know, and I think but for all of our procedures, you know, everyone's everyone still wearing PPE everyone still taking it very seriously and this is you know at a time when our cases are not as necessarily as High when the hospitalization rate death rate is very low, um, people are still people are still very concerned about it. And I I think that there may be an overall change and really how we approach risk of a procedures and really thinking about trying to prevent us from getting sick or getting us sick and then ultimately getting a patient sick. So I I think I interested but other people think but I think for myself I think this is gonna continue on a little bit longer. I agree. I agree if you would stop sharing your screen. We'll move on to our second speaker, Dr. Jenny rise now from the Mayo Clinic She's a unique hybrid of thoracic surgery and Interventional pulmonary Dr. Eisenhower. You're on thank you, Dr. Edel. It's a pleasure to be able to present today and I think that Justice Organization for putting on these webinar Series today. I'm gonna be following Dr. Channick's lead on the subject. And we'll discuss risk stratification of prioritization of lung cancer cases specifically during a pandemic as well as discuss a personal experience with the pros and cons of Telehealth, which is already been touched on a little bit and then lastly discuss single stage Pathways to facilitate early diagnosis and treatment. We'll start with our question. You have a 67 year old male with a 12 millimeter biopsy proven low-grade adenocarcinoma. He was scheduled to have a segmentectomy in the operating room tomorrow, but has tested positive for covid-19 today. He's got mild symptoms nasal congestion and a mild cough how should his care proceed according to the guidelines understanding that there's some variability across institutions but and in general terms, the choices are below which is either to proceed cancel surgery and consider sbrt delay surgery until it's safe per Hospital protocol or convert to a wedge resection because the complication profile is lower than that of a segment Tech to me. We'll give everybody a few minutes here to respond. All right. Hopefully the answer to this question is addressed in the coming slides. So as many on this webinar already know one of the difficulties of managing lung cancer outside of a pandemic let alone within a pandemic is that there's variability in terms of how the patient ultimately makes their way to treatment. There's not the most streamlined care and some of this depends on location of the patient as well as Healthcare disparities, but also access to a proceduralist and procedural time and procedural space. And so when the when the there's already been papers and literature citing delays and diagnosis to this very reason and this is outside of a pandemic. It's understandable that this can be further exacerbated in the situation that we were currently found or solves over the last two years. And so, how can we streamline care? A prospective study that was recently published in the annals of thoracic surgery looked at approximately 300 patients and and the section that I pulled out looked at just lung cancer alone. But this was replicated in esophageal cancer patients as well. And all of these patients were reviewed in a multi-disciplinary tumor board and what they found is that the recommendations after the tumor board met and discuss the patients changed up to 40% of the time including staging and assessment plans, which changed up to 60% of the time and recommendations were followed in 97% of cases when they followed up with these patients several months after meeting of the tumor board and carrying out of the proposed treatment plants. So what that suggests is that sometimes it's better to have another eye look at things, but it's also better for efficiency of healthcare to have multiple brains looking at the same case. So again how to prioritize care tumor board became increasingly helpful and useful during the pandemic I can speak from personal experience when we were all on a culture of Zoom at Mayo Clinic at the peak of the pandemic. We were still reviewing cases on a daily basis and the questions that often came up had to do with the doubling time and the aggressiveness of this malignancy. What's the best way to stage and and do a performance analysis of the patient does everybody need a bronchoscopy beforehand and an e-bus beforehand or can everybody progress safely to treatment if we do progress safely to treatment is that surgery or radiation therapy and if we do consider surgery, is it appropriate to delay surgery by by several weeks or months versus the risk of delaying and considering alternative treatments as we discussed. What we've learned as a result of covid-19 is is there are now guidelines for how to triage thoracic patients and Not only was this published in the DraStic surgery literature, but also in the journal of clinical oncology as just one cohort of a larger group of patients that present with other types of cancer for example colorectal cancer and what they did is divide this up into three phases basically based on the amount of resources that remain the peak within your particular hospital and the trajectory of the of the expected course of cases in that region. And so just to look at these by phases. The first phase is arguably the phase that were possibly in right now where there's ample resources. There's ventilatory capacity ICU capacity the trajectory of cases do not appear to be in Rapid escalate escalation and under this umbrella solid solid lung cancers that were greater than two centimeters or no positive lung cancer or post induction patients that are kind of in that four to six week window should be offered surgery as a priority. The recommendation was to delay a predominantly ground glass less than two centimeters carcinoma carcinoid, thymoma, Olga ministatic or pay any patient that would have a presumed need for a ventilator again. This is generalizable themes. If a physician was in an institution where they were at the tail end of the pandemic or in between Peaks, and there was overwhelming capacity to where now you're talking about or utilization issues you probably We could delve into this third group. We then looked at phase two which were where the hospital had many covid patients limited but not totally excluded ICU capacity limited to our supplies or none of the above. But the trajectory is projected to increase in the next couple of weeks in this situation. It was really recommended that surgery should be considered for more of those semi urgent cases meaning tumors that were infected complications of surgery somebody that was symptomatic maybe had hemoptysis or significant shortness of breath but really defer all those other routine, perhaps stage one or what we call elective cancer cases, and then the last would be phase three which is essentially is the situation a little bit of what I think Dr. Chanic described where all the resources are essentially routed at covid supplies are exhausted hospitals are on triage and many are not even accepting patients. And in this situation the guidelines recommend really only doing surgery if the airway is threat Or there's a tumor Associated sepsis. This is the table that's presented in that paper. And in the interest of time and Clarity, I won't go through each line here. But I think the most important thing to to do is to kind of break this up into stages and again for somebody who is stage one. The question is really can this person be delayed and and do surgery down the road and a couple of months perhaps or is this somebody that needs to have surgery right now and if that's the case consider sbrt or potentially even ablation for for treatment stage two and three are kind of lumped in the same cohort, maybe considering neoadgement treatment to buy them a few weeks to get over the peak and then and then consider surgery kind of in that four to six week recovery window versus considering alternative treatment, meaning definitive chemo radiation therapy based on patient tolerance and patient status. So the biggest question that comes up when you talk about delaying surgeries are we harming patients by delaying their Cancer Care and this was actually studied extensively during the covid-19 pandemic. There's actually been some literature that was reported outside of the covid-19 pandemic and it references that slide that I showed earlier with the variability and Pathways that have led to delays but this study was interesting because again, it combined all cancer types specifically four million patients from the National Cancer database. And with the concluded is that the majority of lung cancer surgeries can wait for four weeks now, they did quantify this or they did put in a caveat saying that these were elective cases and patients that generally were not symptomatic in a way that was harming their activities of daily living and in those situations lung cancer surgery could wait as I said before they did not adjust for patients that had semi-ergent surgery which we Define as opposis or obstruction and their initial and their final conclusions were essentially that this should be individualized to the patient which again takes me back to the previous slide discussing the benefits of the tumor board and having a treatment plan established for that patient. So everybody can agree on the steps that are being on the steps that are taking place. I think it also provides some patience with reassurance because one of the things that we don't get to cover in this webinar, but I think is a significant value to discuss is the anxiety patients are feeling not only from their risk of Contracting covid in the Patient setting but potentially coming in and Contracting it while being hospitalized especially after their recovering from lung surgery. And I think that's where providing that reassurance that multiple providers have seen the case and multiple people agree with the plan to delay helps patients with that additional element of anxiety. So what can we do to expedite care and avoid delays are there any opportunities here to make care more efficient in a seemingly inefficient situation telemedicine has been alluded to Dr. Chanic discuss this and I'll throw in my two cents. I think there are significant benefits. Is that a patient can see multiple providers from the comfort of their own home when we did televisits I often had patients that had dinner cooking on the stove and when they hurt us calling in they, you know, take dinner off the stove and come and do their 15 minute video visits and it was really convenient for them it prevents scheduling delays and and patients don't have to worry about the cost of travel time off of work potentially reducing delays between appointments many times. We have a situation where a patient is contemplating svrt or surgery and they want to speak with both Physicians and get an opinion for both Physicians and having to schedule two different trips to Rochester, Minnesota where I Work or really anywhere around the country and have to take time off of work to accommodate two different visits with two different providers. You know, many many patients are finding significant value in being able to do this over the Internet, assuming that they're technologically capable of doing so and and wanting to do so there have been multiple Pilots with telemedics and that happened published. These have all been done in screening populations or or follow-up surveillance populations. Notably. It has not been done in patients that have been going undergoing consultation. But what they have shown is no difference in the quality a degree of care and time will show whether this remains to be the case in this particular situation. One of the other things that we're doing here at our institution is the single stage pathway. This is where a patient with a high probability of malignancy is referred to Thoracic Surgeons. And this is something that I'm doing in my practice because I am a double boarded Interventional pulmonologist and thoracic surgeon, but we so we offer the patient a single anesthetic biopsy staging and resection. We are currently running the the economic the healthcare economics behind this treatment pathway, but anecdotally it does appear to reduce the cost of travel again the time off of work and potentially reduce the delays between appointments. I think that this pathway has been shown that it's contingent upon a true multi-disciplinary approach with a surgeon pulmonologist anesthesia pathology and Radiology committed to providing this level of care for the patients given that there are some unique and nuances to it, which I'll cover but it's certainly something to think about and I think something that patients were thankful for particularly a couple of patients from Canada that we recently treated. Um, we're very thankful to come down and be able to do it all in a One-Stop shop. This is our room where we do targeted resection. We've got a cone beam CT scanner in the room. You can see here. We've got access to immunoflorescents die and we've identified the lesion of interest and my OR tech there has the stapler ready to go and and here we just did a wedge section on a patient with a small nodule but this is just one example of many of the creative Pathways that people evolved over the last couple of years to get patients that care that they need and deserve. The ideal candidate for this pathway were those with the moderate to high probability of malignancy a multidisciplinary tumor board that agrees with the surgery first treatment approach slightly smaller BMI is ideal just given the the nature of the room and the bed that we do these cases in and the patient is willing to proceed all the way to surgery despite a non-diagnostic result during biopsy. Here's just an example of a case of a patient with an 8 millimeter nodule that had grown slightly in size. That was pet Avid. Um mildly pet Avid given the small size but pet Avid nonetheless. Here's just an example of us performing a cone being CT with the region of Interest highlighted there and the needle going into the lesion. We have a pathologist that comes into the room as we are obtaining these biopsies to let us know that we yes, in fact have malignancy or we don't and once that determination is made we then proceed with Ana bronchial ultrasound staging if clinically indicated in the patient and then if the patient is consented we then flip them over and perform a minimally invasive thoracic resection. Here's just another image of that. And then here's the intraoperative image of the same nodule that's then been highlighted with die. And I think we were attempting a segmentectomy in this patient. So we like to highlight the the lesion would die so that we know our parenchymal margins are safe during the resection. So in conclusion, the urgency and treatment options of patients are contingent upon Hospital resources tumor characters some patient characteristics the tumor board can obviously help streamline Pathways and help guide decision making along with other efforts and despite demonstrated safety and delaying surgery if need be there are things that we can do to reduce time to treatment such as telemedicine as was previously discussed single stage Pathways and other creative options that may evolve as we learn more. Thank you so much. I'll close with the last question here. 73 year old male recovering from a covid-related hospitalization 2.6 centimeter right up or low about and of course Sonoma with a positive 10r lymph node. He requires oxygen right now given that although his pfts prior to his illness were normal. The most appropriate treatment plan in this situation would be definitive chemo radiation because surgery is off the table neoadiment treatment followed by repeating physical exam and imaging alternative treatment including sbrt or three months of observation. Fantastic, hopefully some of that was addressed. I'll stop sharing here and hand it back to Dr. Edel. Thank you very much Dr. Eisner. That was actual. There is one question that came from the audience that I'd like for you to address. I think it's a very relevant question of the topic. The attendant asked do you restay do we restaged does anyone restage patients after four weeks delay and they're referring to a solid or part solid. So I'm assuming a early stage clinical early stage cancer, and if so by what method Well, I'll take a crack at it and then anybody else can jump in if they want to I think if you're referring to what it sounds like is perhaps a low-grade less than two centimeter adenocarcinoma. I would not necessarily restage that patient. I think a patient that the only exception maybe to that rule would be. If the patient showed up with a solid nodule that had a very very high pet Amity where you worry that there's aggressive doubling time. You might could make the argument to reimage or restate that patient or if the patient was delayed because they experienced covid themselves and we're quite sick and you want to ensure that they're parenchyma has fully recovered before you operate on them. You might want to get a CT scan but that's less so for restaging purposes and more for tolerance, I think stage two and three there's there's more rationale to consider potentially restaging but but I would not necessarily subject the patient to a battle with their insurance company for stage one disease. Excellent. Another question came through and I'm going to ask Dr. Chenick to take this one. It had to do with the use of PCR screening before procedures. The question was are we still screening before procedures or are you just going by what the local rate of infection is? throughout the country what we're still doing and it is something that is absolutely flux because at one point maybe six or so months ago more than six months ago. We completely stop pre procedure testing for all of about two weeks. And then the numbers started to go up and we reverse course and the procedure testing continued and I think we are continuing to test patients. Our protocol is they have to be tested the test has to be back within 48 hours and it has to be a PCR that has made it very difficult for some patients that we're getting more flexible and we will test some people even on the morning of the procedure. If someone is covid positive they they will do the procedure. They will do a PPE and then we'll do it at the end of the day, so we're not refusing even elective cases. The hospital is still allowing that excellent. Excellent. Thank you. Okay, so we will now shift gears a little bit Dr. Flores is our medical oncologist from the Dana-Farber Cancer Institute. Hi everyone and the lady to be here and I really like the progression at the top we started with pulmonology then surgery in the medical oncology. And that tends to be the pathway for many our patients. They be with the pulmonologists then the surgeon the medical colleges hopefully all at the same time or close to but sometimes it's just sequential. So we're gonna talk about not only diagnosis but treatment during a global crisis. This is question. Number one, which of the following is true about lung cancer screening during the pandemic. We make most reference to the last two years more patients where they knows we lung cancer during the pandemic. Cancer screening is no elective. So it continues usual. Praise the lung cancer screening decrease during the first part of the pandemic but improved during soccer months. So you can vote now. All right. We have people that went home the majority went into a Direction. So this is a patient that I sell in clinic during the beginning of the pandemic. I was still at the University of Wisconsin. So these are 63 year old Hispanic women Highly Educated no significant past medical history be known English speaker. She alcohol primary care doctor due to worsening cough and weight loss. So we're talking about Juno 2020. Of course, she go for different covid tests. Later. and several under a Texas rate was done. The patient was not allowed to come into the primary care doctor's office because of the fear, you know a golf. and I think that's something very unique to our patients because Most of them have a cough and I remember talking to the nurses as I they have a cough what else you know, because mother or patients have the symptom. So to respond to have a long mass and during the very hectic pack of the pandemic. She received a phone call in English. Only telling them that there were something in the Texas rate that should be follow but as I know English speaker, she didn't understand the message and that subsequent delay her care until she became a stitch for patient with multiple liberians. So that story is Common, I met her at the time of the bat scan, but that we have seen how covid had delayed diagnosis how Kobe has affected patients taking care particularly minorities because the high rates of mortality for vulnerable populations. So the common pandemic change the entire spectrano Cancer Care including the lace and diagnosis treatment and haltingal clinical trials. I remember at the beginning of the pandemic talking to my colleagues in Italy as they have a number of cases increasing compared to the Midwest and the Midwest were a little bit Shelter From the coast and it took a little bit longer compared to now where I live in Boston, they have 500 violations of clinical trials in the first week. Violations is out of protocol. So many clinical trials were close to recruitment clinical trial discussions were now taking place. We're all an emergency mode. In 2020 covid-19 was the third leading castle that in the United States after cancer. And I cannot stress enough how many people we continue to lose? This is 345,000. We know this is past five hundred thousand patients at this point. As a medical oncologist is often hard, you know many our patients are. Staying alive or you prolong their survival through chemotherapy and immunotherapy at the early at the beginning of the pandemic. I remember getting a phone call and saying now you're gonna run round. For an outside of the room and only one provider is gonna come in with all these PPE and these patients are most likely to die alone. And I try not the Mayo Clinic and nobody prepared me. For having so many patients we end stage cancer dying alone. I think there were Sony sections at the end. I think I begin in 2021. We started making it sections for family to come over but I remember holding my phone next to my patients. In FaceTime with their families other passing away. So I wrote this article because I remember laying down in the floor of my office. Thinking should I post on this adjective and chemotherapy because the chemotherapy benefit adjuvenly is kind of borderline for a long cancer. Should I continue with this startup before these patient which therapy is better for these patient into this Global crisis? And at the beginning there was no data. So everything was based on the patient comorbidities what we were doing and some patients made decisions on their own and I remember discharging patients home. Probably early on hospice. Because I wanted to be home. I wanted to die at home the spice needing many things and I I think we learned quickly how to provide empathy cover of PPE. I remember Labor Day my chill with my name. So they knew it was me and It was way a lot with their emotions. So subsequence subsequently data came out to understand we which treatments for patients could be saved in which could not be safe. So I'm part of the steering committee. Oh CC 19, which is the cancer and covid-19 Consortium is the largest database of cancer in covid in the United States and little by little we come out with new data. We learned that immunotherapy and Target therapy no increase mortality in these patients. We learn certain patients where a higher risk for ICU complications, but the data came fast but if you can see the days of publication of these papers, the first one was just a review and that was a May 18 or 2020. So we have around two three months without no data and the subsequent papers are playing play published in 2021. This is relevant to lung cancer. This is a whole analysis of the covid-19 cancer Consortium and included many of the studies that were published because we saw so much data coming. So the beginning we were in a phase that was no data, right? We're like, what should I do on a scratching my head remember talking to my friend Dr. Garissimo in Needles? Like why are you doing over there? What is happening? Just try to get some information early. But then we saw as I editor. We saw this increase large number of papers those sometimes hard to keep up. So these men analysis that was let by one. Oh my mentees so that overall the mortality for patients. We met a study alone cancer was 15 to 30% and of the patients we cancer that have the highest mortality the patients with long cancer. Obviously, we're in that group. So what are the consequences of covid-19 in Cancer Care in the US perspective? So we have the lace and diagnosis the lacing treatments and we have early dismissals on hospice. I saw it personally and there's many papers about that. But something that I so personally and data should stage migration. And what it stage migration is when we trans. When we see the data from 20221 for patients with lung cancer patients were most likely to present to the ER we are made aesthetic site in symptoms that being diagnosed early and that really is relevant to the first question during the first part of the pandemic. We saw a decrease in the number along cancer screening and we already doing very poorly. We lung cancer screening to be clear but then the number significantly decrease after that. We also so the fear of coming to the doctor which is often seeing until medicine help with some of this but so now my newly diagnosed patients where like, well I didn't want to go to the doctor who wants to go to the doctor and up endemic and I remember my nurse saying we're not the hardest place in town right now to visit. We're a hospital so many patients they lay seeking care particularly vulnerable populations in Is that lost their employment during the beginning of the pandemic because their insurance was related to employment. So it's not only the consequences of the virus but the social economic consequences all the pandemic itself and people being sent home to work restaurants closing movie theaters closing and these people lost their insurance. So going to a doctor meant a very big deal when they're currently unemployed. So this is the initial paper that show the decrease along cancer screening and the first phases of the pandemic. And the most this is particularly the first month before like before before they covid-19 search. This is a single institution analysis and then how it decreased during the search and also the number of new patients and the number no shows were for 15% to 40% and I don't have to preach to the choir that lung cancer screening says lives here in a chests Symposium. But also how early we're doing about it. During the pandemic. They're also changes to the guidelines with the hope to grab more minorities that already know really really screen and the guidelines change as you can see, there's one all the low on all the guidelines is a little bit controversial, but the hope is that we were gonna do better with lung cancer screening and that affects some of the numbers that we saw in the second part of the pandemic. So what has happened? So there's two faces. There are Q phase of the pandemic the lung cancer screening went down then we slowly recover and the NCI in the American Cancer Society release grants to motivate re-initiation or return to screening. This was just present that I asked. Oh less than a month ago. This is particularly for breasts for other initiatives has been seen and which increased the implementation of screening is still win the environment of the pandemic and and we're seeing more and more data how we can learn from this crisis to continue to screen our patients. Something that really happened with the pandemic as many of the disparities existed in lung cancer widen. People loser insurance people didn't have the financial resources to look for health. Bonoba populations blacks African Americans and Hispanic in Native Americans have jobs that which they don't have the privilege of going home increasing like working for home increasing the race of infection. Many of my minority patients work in grocery stores public transportation janitorial services in the hospital and I remember they told me I have no I don't have the option to go home. And I remember talking to some of my immigrant patients. It's like to say to stay away from my family members. We're a very big family a very small space. And something that really shake me to the court was these results in 2021 and we showed that the patients with Medicaid before covid. Were more likely to die in the hospital compared to Commercial Insurance. We knew that because it's limited resource and support at home. But during covid Medicaid patients were more likely than commercial patients Commercial Insurance patients to die at home without hospice and I highlighted in these light because dying without pain and dignity is a human, right? Hospice services are covered by Medicaid. So many of the challenges of these patients with metastatic cancer. increase as people were dying at home without hospice. And then repeating it so we can think in a little bit. We have talked about. Telemedicine and telemedicine has been a great resource for areas or remote. We talk about I was at Mayo before and you know traveling to Rochester's various expensive. You have to buy a hotel you have to travel flight and to Boston too. And that improve access to Physicians. So I'm gonna talk about the prostate telemedicine improve access it allow. Members of the family to join very important conversations for different parts of the country allow International patients to have opinions for Physicians during the emergency. time in the United States But there was also a challenge we tell medicine that we continue to see a new data has been published about this and as if the patient is no English speaking actually provided digital divide. Because it was less likely that I interpreted was incorporated into the telemedicine Bisset interprets were already very few and Stranded so I know saying no to do telemed medicine. We have patient that English is not the first language, but I use the appropriate resources to support it. and the digital divide is real we many of us take care of farmers. I took our farmers in Wisconsin, and I remember some one of my patients had a phone that I can call him in the farm next door. So I needed to call that farm that we answer and then we get Walter that's another real name to come and answer the phone and I remember my Medical assistant college like are you interested in not telling medicine appointment water and my patient is like I don't even have a computer. So for some patients that have very limited resources. We need to listen to them. The telemedicine may not be possible. It is there and it's helping another console of telemedicine is that after we learned the benefits of telemedicine the emergency order was removed and now patients that were previously seen out of state by telemedis and now you can And it's like literally we just keep our patients a benefit and because unclear reasons. That benefits being removed and that has been very difficult. I have a patient for Nigeria that I was talking to her and we're all fine. And now she has to come in person for a service that she was getting before via telemedicine. So a lot of Institutions are credentialing a licensing their doctors in different states. So the benefit continues I'm currently licensed at all New England in order to provide those services and I'm actually licenses in Florida now because a lot of our patients go back to Florida and the winter So remaining challenge with the pandemic we still don't know the long-term consequences. We are seeing an increase or number of cases right now again, not to the point of Omicron in January 2022, but we're seeing a number increase of cases people are going now. I don't know if any of you have fly recently. I tend to fly a lot and every time I take a plane, there's less lengthy, but we must and Screen erase not only in lung cancer, but all the diseases remain very poor certain areas. What are the consequences of covid-19 and cancer research? Many trials were delay many trials didn't open. Isd's holding some of the research in 2020 2020. We have seven different approvals for lung cancer, but we cannot see those approvals as a 2020 win. That was his research that was set of many years before to get to the approval. So are they approvals in five years for now gonna be delay, especially as with the the Bellow new targets and lung cancer. finally, we continue to fail almost vulnerable populations and some of the most vulnerable populations that patients will lung cancer and which they have limited resources limited capacity financially and physical to make it to appointments and you know, I have to say I continue to be afraid with my patients when they get covid-19 infections, even if they're vaccinated because I have lost several of the patients to the disease and it's so hard to lose a patient. That you know, they dealt with early mortality with their cancer. The cancer is doing better adaptation. We are complete response and Target therapy and then covid to care away from me. And I think that was very hard for the days for the family and there are many issues with social justice. We covered in what we happen after. So as I wrap out this webinar is covid-19 delay diagnosis treatment and life care of patients with lung cancer. In this show that as a healthcare system, we're able to get all handsome deck land furniture on each other and work towards the Improvement or patients. We focus on a dispolitics red tape and things that sometimes delay treatment and we were all on working together. Estate migration as a reality is still continuous. Telemedicine integration is not going anywhere telemedicine is here to stay. And a big proponent of telemed medicine and particularly with my patients are in targeted therapy. They're taking appeal every day, you know driving from Maine to Boston. It's gonna be five hours. But we still don't know the long-term consequences. It's a part of the Care instead of part of the conversations. We are patients. I have a patient that's getting for Eva's tomorrow. And I told her don't interact with anybody that you don't know because you're gonna get tested for covid today because that we delayed other things. All right questions. Number two for patients with lung cancer. All Commerce. They Associated covid-19 infection mortality was less than 10% 10 to 30 and higher than 35% You can vote now. I'm gonna stop sharing so we can answer questions. We are on the top of the hour. Excellent job Dr. Flores. Very compelling right spot on I'm gonna ask a question and there is one in the chat box that we can do it as a panel. Hopefully people won't mind if we go over a couple minutes. With what you have heard from all the other two speakers and what you presented Dr. Flores. Where we what we've learned from the pandemic what we've learned from our Healthcare System that those lessons that we take now with us. Does it give you? Optimism or are you frustrated that we can do better in the future? I think um, it gives me material. Let me tell you this because sometimes I encounter issues in which oh these clinical trial the blood draw needs to be a Dana farmer. It's like it is a CVC. Like my patient is a man. I'm gonna get her dry five hours for a CVC. So we learned that we can be flexible. So let's stay flexible because everything we do is for our patients. Let's remain flexible for things that don't affect care significantly. She can do the CVC. I made she did last year, right? What are we switching back? And I think something that really helped me. positive is that we can quickly learn. And I see tradition as a obstacle Innovation and learning quickly. during covid-19 makes me hopeful that maybe one day long cancer will become a chronic disease for a stage four. Excellent doctor Janik Dr. Eisenhower optimistic frustrated. Dr. Jennik timistic excellent doctor right now. Hey optimistic, you know, I think that that sums up pretty well. The the flavor of what we've learned. I would say that when this pandemic started I was scared and really worried and what I've seen as a as a member of this community, I've seen nothing but pride and optimism, I agree the last question that came through the chat box. I want to address it from that from one of our attendees is do you do you think there is a role for prophylactic and you shall during chemotherapy? So any role for prophylactic antiviral during chemotherapy quickly? It has not been studies. I don't think there is a role a there's one quick article that shows that actually may increase successity. So at this point excellent, excellent. Well, I want to again thank our outstanding panelists. I want to thank Jess for putting this tremendous webinar series together. I would love to have our attendees refer back to the previous. For webinars that we had there was a couple of questions that came through that had to do with liquid biopsy and genetic markers in lung cancer that was addressed in our third webinar. I'd like to thank our industrial Partners again as presentica Genentech markshark mendome because we can't do that without our industry Partners helping to support with their educational grants. And finally, please go to chess.net for other programs that the the chest puts on in you all. There are attending will get a question in the in your email at 30 days and 60 days as part of the program to help with our space learning help anchor some of the lessons that you've heard from our our panelists today. So thank you again everyone have a great evening and I hope to see you someplace truly face to face not virtually face
Video Summary
The webinar focused on the impact of the COVID-19 pandemic on lung cancer management. The panelists discussed strategies for optimizing the timing of diagnosis and treatment during the global crisis. They emphasized the importance of not forgetting about the ongoing COVID-19 pandemic, as there are still a large number of deaths occurring daily. The panelists also discussed the challenges faced in managing lung cancer patients during the pandemic and highlighted the need for proper prioritization and utilization of resources. They also addressed the impact of the pandemic on various aspects of lung cancer care, such as delays in procedures, telemedicine, and risk stratification. The panelists shared their experiences and provided insights on how to overcome barriers to lung cancer care during the pandemic. They emphasized the importance of a flexible approach to care, with a focus on patient safety and timely treatment. The panelists also discussed the role of telemedicine in improving access to care and highlighted the need to address issues related to the digital divide and language barriers. Additionally, they discussed the impact of the pandemic on lung cancer screening, treatment, and clinical trials. The panelists expressed optimism for the future, noting the lessons learned and the ability to adapt and innovate during challenging times. Overall, the webinar provided valuable insights into the management of lung cancer during the COVID-19 pandemic.
Keywords
COVID-19 pandemic
lung cancer management
diagnosis timing
treatment timing
prioritization
resource utilization
telemedicine
barriers to care
patient safety
clinical trials
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