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Alicia Morgans: Hi, my name is Alicia Morgans, GU medical oncologist and Associate Professor of Medicine at Northwestern in Chicago. I am so excited to have here with me today, Dr. Sumit Subudhi, who is an Assistant Professor of Medicine in the Department of GI Medical Oncology at MD Anderson. Thank you so much for being here with me today.

Sumit K. Subudhi: Thank you, Alicia, for having me.

Alicia Morgans: Wonderful. I wanted to talk with you a little bit about how things have been for you as both a GU medical oncologist, as well as someone who is really intensely engaged in research in the Houston area, as we're trying to deal with the COVID-19 pandemic that is ongoing and really hasn't given us a break, particularly in places like Texas. How are things going?

Sumit K. Subudhi: Yeah, so things have actually been difficult with our patient interactions. We are trying to limit the spread of COVID within Texas, but many of our patients also live out of state or international and so that's offered another bit of challenge in how to deliver life-saving care to them in a reasonable way, without increasing exposure to them and our staff. And so one of the things we're doing is going through every single patient ahead of time, about a week or two, and seeing which ones we can do virtual visits with as opposed to asking them to come to clinic. And then we're also trying to engage with the local medical oncologists as well, to see if they can help administer some of the therapies and treatments so the patients can avoid an unnecessary trip to a place that's highly exposed. That's helped quite a bit, but it also increases a lot of anxiety with the patients because they're used to having their care delivered exclusively by us. And so handling those anxieties has really added that major challenge to us.

Alicia Morgans: Yeah, but I think you make such an interesting point about MD Anderson being a unique place where people do drive for hundreds of miles or many times get on a plane to come down there. And these are not times where that's really going to be the safest thing, particularly for people who have cancer. I think that's really wonderful that you are able to try to make those changes for patients who are able to not come in person. That can be more challenging for patients who are on clinical trials or who want to engage in clinical trials. Are you making adjustments for those patients? Or are they still able to come in and I think you have even housing where you can help patients stay safe within an MD Anderson kind of a housing situation. Are you able to keep the trials rolling?

Sumit K. Subudhi: Yeah. In the earlier phases, so right now where we feel we peaked in the pandemic on July 19th and that our numbers are starting to come down, but as the numbers were going up, we went into a phase one where only patients that were receiving oral medications could continue on clinical trial and so that the medications could be mailed to them and so they could avoid unnecessary visits. The ones with infusional drugs were being held until phase two and then phase two opened up about a month or two ago. And so we've been able to do that, but we put on hold for a long time opening new trials. And even if they had passed through the IRB process, and even if there was a SIB, we were not allowed to open new trials for accrual.

That is no longer the case. Now we're slowly opening and ramping up, but we're not opening everything at once just to make sure we don't overburden the system. But we're still as much as possible, even with patients on trial, implementing virtual visits. And I have to say that, there's a lot of bad that comes associated with COVID, but there are some good things that have occurred and it's made us look at our work processes and see where we can improve efficiencies. And I have to say using this virtual approach, we're finding that we are actually decreasing our patient wait time because instead of having multiple people going to see the patient in a room, a lot of stuff is happening virtually and the patients that do need to be seen by the physician are just having time with the physician so the wait times are significantly less. So, there are some good things that are coming out of it.

Alicia Morgans: I would agree with that. There are definitely days where you have a very full clinic schedule and one person is very ill or maybe a couple people are very ill, you have to send them to the emergency room or take care of them, then the rest of the day can be, even for patients with very routine visits, can be thrown off. And those wait times can go up, which is frustrating for everybody, including the docs who are trying to do their best to stay on schedule. But, of course, we need to take care of patients in whatever capacity is necessary. So, that's a really, it's an interesting point. And I agree with you, my clinics have run more on time, actually very much on time when there are a number of virtual visits. Certainly, patients are probably lower acuity, but also we don't have those wait times in rooms. That's a really great point. Are you at this point doing mostly video teleconferences? Or are you mostly using phone interface? What are you doing for that?

Sumit K. Subudhi: I personally am doing more telephone conferences, but I have a lot of colleagues that have gone more to the video. One of the things is that it's just my office we haven't set up in our clinic efficiencies with the video conference. I have to go back to my office to do that so it's more trying to be more efficient with my own time that I've done that. The other thing is that a lot of patients of mine have iPhones, and so I'll FaceTime them when possible and use that as well.

One of the challenges we've been having is the daily updates by the CDC are changing and evolving and that communication can be challenging because as that's coming from CDC, our leadership is trying to pass it on to all the staff. And this actually happened just this week where I found out what it's like to be a patient because we go through a screening process every single day as a staff member, but one of our best friends, my wife's best friend got diagnosed with metastatic thyroid cancer.

And so she went to the new visit and consult. They said, "Oh, you know what? You can go to the surgical. You can come with your friend on the day of surgery as well, and stay with her as long as you want." But then there's a change in policy. So the day of surgery, she wasn't allowed to go in. And so it really caused a lot of anxiety on both the patient and the caregiver. Or in this case, a friend who actually flew in to be quarantined. She's from South Carolina. She flew in to be quarantined for 10 days before the visit, got the COVID testing. And then... so there's a lot of anxiety and I got to see it firsthand from someone that's very close to us.

Alicia Morgans: I really appreciate that you bring that up because it's not just that patients are feeling isolated, it's also the changing restrictions that happen sometimes only hours before you are supposed to be the support or have that support that you need as a patient. And particularly in settings where we might be giving people bad news, it can be so challenging. And what I also find challenging is that at least in our institution, the cancer center has its own specific set of rules, but other practices might have more relaxed rules. And so just this week I had to have a conversation with a patient — it was not a good situation, it was a new diagnosis and there was a misunderstanding of the extent of disease, which ended up being quite large. And his wife, wasn't able to be there with him to hear that information when she thought that she was going to be able to be there. And it was really upsetting.

And we also we'll call that family member on the phone and have them participate but that is entirely different than having someone sitting next to you, holding your hand or giving you a tissue or just being present, and it's really hard. I really appreciate you bringing that up and I know that patients are definitely dealing with that. And we as clinicians are also trying to figure out what is the best way to do this because I felt terrible and definitely did not want to put anyone in that position. But we don't always have control over those rules.

I also know that you do so much research. A lot of it is related to immunotherapy and there's been some talk about whether patients who are receiving those immunotherapy type treatments may have more extensive disease or reactions if they are infected with SARS-CoV-2 or develop COVID-19 syndrome. What is your experience in that realm? Both for patients who might be receiving those treatments just routinely through your clinical care or for patients who are receiving those treatments, some of which can be really on the more intense side, in clinical trials?

Sumit K. Subudhi: Yeah. We're really monitoring those patients carefully because we're not so worried about the drugs themselves, but you're correct, if a patient gets infected, one of the issues with COVID is the cytokine release syndrome that can occur. And we know that the immunotherapies could actually boost that and make that worse. We are really engaged — where the patients on all our clinical trials, at least in our department, have our cellphone numbers and they're really encouraged to call us if there are any signs and symptoms. Education has gone a long way where we're really talking about the symptoms that you should be looking at and then, in addition, we're proactively calling most of the patients once a week. Either from the physician side or from the research side so we have research nurses and data team members that can actually do this for us because we just want them to know that we're taking this seriously. And we have not had a single issue with that from our department, which is great.

Alicia Morgans: That is great. And we have not either, I've actually not seen good data to support that those kinds of cytokine release syndromes are increasing in patients exposed to things like checkpoint inhibitors are CTLA-4, but it's something definitely that we think about. Something to keep an eye on. And I know that there's ongoing research trying to sort that out as well. I'm glad that your patients have been well. As we wrap this up, what would your message be to other clinicians or to patients who are watching, who are trying to cope with living with the new normal that we are experiencing in the ongoing COVID-19 pandemic?

Sumit K. Subudhi: Yeah. One of the things, the bad things I've seen happen is that our patients are not communicating as well their symptoms that they may be having that are cancer-related. And in their minds I understand what they're thinking, right now there's a surge, I don't want to increase my exposure. I'll just tell my doctor next month when things got better. But as we're seeing that there's this up and down that sometimes happens with COVID, meaning there can be things look good and all of a sudden there's a new surge and things change and it becomes worrisome because as these symptoms worsen, they can actually become more life-threatening. And so I really encourage them to still keep in communication, understanding that they may not be able to have face to face communication but it's really important to contact our clinic and let us know what's going on and we will work with them to make sure that we limit their exposure to COVID, but maybe put some interventions in place locally so that they don't have anything that's life-threatening. That's my biggest concern or challenge that we face.

Alicia Morgans: I think that's a great message. Both to patients and also to clinicians who may adopt for those higher-risk patients or patients who seem to experience more side effects, the strategy that you and your research and clinical teams have, which is to reach out to those patients proactively maybe once a week, every other week, perhaps, based on their bandwidth to ensure that that communication and making sure that we are all clearly understanding what is going on with patients is not severed because it can feel like, as you said, it's a dangerous situation and I don't want to put myself in harm's way. But certainly, we would rather prevent what we can, rather than be afraid of things that might happen. Thank you so much for your time, your expertise, and I wish you, your team, and your whole family the best of luck as we move forward.

Sumit K. Subudhi: Thank you, Alicia, really appreciate that.