Interview recorded on April 2, 2020.
Dr. Moon: So, let’s move on to a much more, I think, somewhat controversial bucket, which is the metastatic hormone-refractory prostate cancer patients. I’m specifically not thinking about the patients who are responding or stabilized on the enzalutamide, the apalutamide, and so on. I’m thinking about the patients who are starting to run out of options, right? Who, because of CHAARTED, we may be thinking about putting them on cabazitaxel, or maybe we’re trying to weave in a chemo in between the two ARs, or maybe looking up PROVENGE, or maybe calling our radiation colleagues to pick out growing lesions, and so on. What are your thoughts about that? And I’m going to actually go to Dr. Harris first to talk about, it’s rare but it happens, but the palliative radiation, and I think you may have alluded to that earlier, but maybe in this context, let’s chat about this.
Dr. Harris: Yeah. So, you know, outside of the curative setting, there are a number of reasons that one might decide to pursue radiotherapy. So, for patients who are seeking palliation of specific active problems, that discussion becomes one of comparing radiation with the alternatives, and I’ve had a patient decide that they were going to pursue anti-inflammatories for a couple of weeks and check in again, and many other patients who just can’t wait. And then, there’s a number of abbreviated bone regimens that are preferred, like 8 Gy x 1, that help try to minimize the total number of contacts.
When it comes to targeting of stereotactic lesions either that are painful or for patients who are in the middle of their treatment course, where that was planned, I’ve been having discussion with those patients individually. Part of what I personally am worried about is that this is not going to be a discrete event. We’re not going to get word that all of a sudden, it’s time to open the ORs. This is going to be very protracted. If history has taught us anything, it’s that these types of events have a little bit of a cyclical nature. And so, one of the reasons that I personally might differ a little bit from my colleagues on this issue of deferment is that we know that there’s a subset of unfavorable-risk prostate cancers that are really bad and that we are sometimes wrong about whether or not a particular oligometastatic site is going to remain stable. And it’s very unclear to me what the specific release valve is going to be when we’re told that we can now safely proceed. And in that setting, taking a large group of patients potentially and telling them that we’re deferring to some future potentially safe time is not an approach that I personally favor. I think that the onus is on radiation oncologists, who have more flexibility than surgeons, to potentially do very dramatic things, to make it safe for patients to get the therapies that they need. It’s both that I don’t think we’re going to know when it’s “over,” and also, if you do stop, when it is “safe,” how do you troubleshoot among a huge sea of patients who have been told that you’re going to get treated as soon as there’s a go?
And it is true that this is an unprecedented crisis, and in New Orleans, we’ve been hit as hard as anywhere, but I can tell you that operating 3 weeks, we have no personnel, faculty, or patient transmissions in my department, so there are things that can be done to make it safe and should be considered for those patients that, unlike a short extension on your new adjutant hormones, where you’re really considering what would be considered outside the standard of care, to have a really careful discussion about that because we don’t know the future, and we are sometimes wrong about the behavior of the patients’ cancers who we’re caring for.
Dr. Moon: So, what I’m hearing from you, Dr. Harris, which I think are actually valid points, and sometimes in our rush for safety and shutdown, I don’t think we actually pay as much attention to it, which is, these patients are not going to [a] diminishing pool, and if we variate too much from the standard care, we may have to pay that bill later, and it may just be too much to bear for the system and for the patient.
Dr. Harris: Well, so, I think that Dr. Silberstein makes excellent points about the OR, but in terms of radiation clinics, we’re operating any day, every day no matter what, right? We’re not going to go to zero, and so the management of this resource, this resource to provide potentially curative and palliative radiotherapy treatments must exist. So it’s not using more resources to treat additional patients, but considerations become what are the additional risks of coming out of your home, and how can those be mitigated, and how are they weighed against what the alternative is? And for some patients under my care, the alternative has been better, so we’re doing the alternative. And for others, we’re not.
We’re doing a complete wipe down of all the immobilization and the room between patients for surfaces, and the immobilizations are being stored in separate bags. If we were to have a COVID-positive patient, that patient would be treated after the last patient of the day. We would then engage additional cleaning support, and we actually have a separate...a physically separate space that those immobilizations would be placed on, and all of the immobilization used, after wipe down by people in full PPE, would be placed in a sealed space.
Those are some of the steps we’ve taken. We’ve also asked for access to something called PRN, or as-needed, radiation therapists in case we do have a large event. We’ve been very strict about anybody with any symptoms. They need to stay home until they’re tested on the staff side. And as I said, we’re taking temperatures, everybody, myself, all our patients get a non-contact temp on entry and a mask.