Alicia Morgans: Hi, this is Alicia Morgans, Associate Professor of Medicine and GU medical oncologist at Northwestern University in Chicago in the United States. And I am so honored to have with me here today, Dr. Karim Fizazi, who is the GU medical oncologist in Paris, where he's also the Head of the Department of Cancer Medicine at Gustave Roussy in Paris. Thank you so much for being here with me today, Dr. Fizazi.

Karim Fizazi: My pleasure, Alicia. Thank you for having me.

Alicia Morgans: So Karim, we have invited you here to lend your experience and expertise as a GU medical oncologist on the unfolding COVID-19 pandemic to really lend your view from the perspective of one physician in Paris to help the rest of the world get a bit of an understanding on where things may go and how they may adapt to best practices to best care for patients while we're experiencing this really unprecedented phenomenon. So, can you tell us a little bit about what you and your colleagues are experiencing at Gustave Roussy in Paris right now?

Karim Fizazi: Sure. We have quite many COVID-19 people, patients already in Paris. Currently, the situation, I guess, is mostly under control. We have enough beds at the hospitals and also at the intensive unit to take care of patients who are coming to us at the hospital. But this is rapidly growing and, of course, I really don't know whether this will be the case in the coming days. Now, regarding other cancer patients, so far it's been okay and it's also quite under control. We've made the decision to launch a service, a COVID-19 service for oncology patients here Gustave Roussy with basically two areas. One is for patients who are positive so that they will not contaminate the other patients. And the other place for patients who are suspected to be positive. So before we have the results from the PCR test, we are putting patients there. And of course, we're rotating our senior doctors to take care of these patients.

So this is quite new, we just started this a couple of days ago. Again, the number of cases still remains under control at the moment, but it's rapidly growing, so we'll see in the coming days or weeks what it does. I guess it's very hard to provide recommendations to colleagues regarding how to best treat, currently, all the patients with GU malignancies. But the main one I would make is simply to avoid patients coming to the hospital. One, it's possible, so that we can prevent them from getting the virus there. We have data from China indicating that the risk for patients with cancer or with comorbidities to develop a serious version of the disease is much, much higher than what it is in the general population. So I think this is a very pragmatic and very simple prevention strategy. Now, of course, there are some patients who need to come to the hospital because they are in need of care, and we'd have to deal with that, of course.

Alicia Morgans: Absolutely. And as you are seeing these patients and knowing that they may have poor outcomes, which in the publication out of China included things like ICU admission and certainly death related to COVID-19. As we tried to avoid those poor outcomes for our cancer patients, are you thinking any differently about the treatment choices that you face? For example, in men with prostate cancer, as you treat them, whether you see them in person or over the phone or however you're doing your remote visits, are you making any different decisions with treatment?

Karim Fizazi: Right. Yes, indeed. For example, I'm doing most of my clinics over the phone or over Skype. I'm trying, really, to see a minority of men. Yesterday, for example, I had a full day clinic, I saw probably only four patients, physically, and all the rest was over the phone. And actually it's doable in many ways, advanced prostate cancer, for most of them to assess things. As far as you have their images, the bone density scans [inaudible] a variable to send you the labs, and you can ask them how we feel, how they're doing their treatment, most of it can be done by the phone. I think we can probably also make some recommendations, and of course, this is level, 100, because we don't really know what is best for the patients. But just to be pragmatic for men, for example, we've localized prostate cancer for patients with good risk at the moment. I think very clearly, active surveillance should be strongly advised to all the men.

For patients with localized disease and intermediate prognosis, I think for most of them we can probably postpone the local treatment by two months without any harming, and if we're really anxious we can start ADT and then use radiation therapy, say, starting next summer. And for men with a high-risk localized is the same. I think the most practical recommendation would be to start ADT now and start with radiation for three months' time to avoid the risk of surgery for these patients, knowing that not all patients will have a label intensive unit that, if they were needed, of course.

Now for patients with metastatic disease, for those who have been in the metastatic disease where basically we have different options of labels, at the moment. I think, with the 19-COVID epidemic we have a very good reason to avoid using chemotherapy with metastatic in the coming months, so I would strongly recommend or advise ADT plus next-generation AR agent targeting with either enzalutamide or abiraterone, depending, of course, on the label in all the early phases.

Now for patients with castration-resistant disease, when doable, I think enzalutamide should probably, or apalutamide, of course, or any other AR targeted agent should be preferred over chemotherapy when doable. Also, probably when we have a choice, we should probably use enza instead of abiraterone, because abiraterone needs steroids and we don't really know where the steroids can increase the risk.

Now in some cases, of course, what with symptomatic patients who have exhausted these options, chemotherapy is probably needed. My advice would be perhaps to start the first injection. I would do, say, 60 milligrams for the perimeter of docetaxel or perhaps even 15 milligrams per square meter of cabazitaxel when needed, and I would strongly advise using GCSF support, starting from the first cycle. And of course, we may adapt as time goes and depending on the epidemic.

Now, also very important in GU oncology is a situation of a young man with germ cell tumors, because this is usually curable. I think we should not postpone orchiectomy when we can. The recovery is usually very fast and that can even be done as an outpatient treatment, at least, in some men. For patients with stage 1 seminoma or non-seminoma, I think it's very reasonable at the moment to avoid any adjuvant chemotherapy. Surveillance is probably a good choice with treatment, in case the patient develops metastasis, but that can take months or even sometimes years, so again, the epidemic will hopefully be behind us. Now for men with evidence of metastasis, of course, it's more complicated to make a decision. Probably we should not postpone too much treatment, this might be dangerous. For men with advanced seminoma, I think we have good reason to try to reduce the amount of treatment. We just reported, for example, the seminoma data at ASCO GU, showing that just two cycles of cisplatin etoposide so without bleomycin can be done safely with a PET FDG right after, and a decision according to that to try to limit the number of chemotherapy cycles.

Now for men with non-seminoma metastatic disease, I think we have two bad choices facing us. Either using BP, so bleomycin [inaudible] and cisplatin with a risk that bleomycin might harm the lungs, and we really don't know whether bleomycin can increase the risk of fever forms of 19-COVID disease. Or replacing bleomycin with ifosfamide, with, obviously, no risk for the lungs, but a higher risk regarding neutropenic fever and perhaps see again more serious forms of the COVID disease. So I don't have, honestly, the answer between these two choices. I think we have to make a decision on an individual basis, perhaps depending on the age of the patients, depending on whether he's smoking or not, all these things. But probably we don't have evidence to help us, for sure, make a decision. So those are, just in a couple of minutes, the main situations I think we are facing, obviously. And when we can either postpone treatment or try to make the best decision.

Alicia Morgans: It's interesting, your comments on bleomycin versus a VIP treatment, which, in the United States and I believe it might be similar in Paris, is something that, previously actually, for us, BEP would be a real go-to regimen for these patients with really only switching to VIP if that was absolutely necessary because the patient had a heavy smoking history or some other reason that really pushed us in that direction. I actually had a patient come in just, I think it was early this week, who has been on BEP and he needs four cycles of BEP, and said, "Well, should I continue with my BEP as an outpatient?" And he's on cycle three right now, "Or is there an alternative?" And rather than switch them to VIP, which would then also be an inpatient regimen, so we're facing a shortage of elective admission, inpatient beds, as well. We actually continued on BEP. He has excellent lung function and we hope that he will stay free of infection, both from a neutropenia standpoint, and also continue to have his excellent lung function with no COVID-19 exposure.

But it is a situation where there is not a perfect answer. And it's interesting that you're already thinking about this and trying to help make those choices for your patients, because as I said, I just had to make that choice earlier this week for mine, and hopefully we've made the right choice, but there's not really a clear right answer in this.

Karim Fizazi: I agree. It's a pretty tough decision to make, and because it's your place, you're able to give BEP at an outpatient regimen. This is also something important to take into consideration, as you said, versus VIP. I mean, hopefully, we'll have more data regarding those questions in the near future and we will be able to publish those to help colleagues and ourselves. I guess at the moment, we just need to be very pragmatic and question all of the medical decisions to try to find the best one.

Alicia Morgans: True. Well, as you think about all of these things that you've learned and all of the struggles that we have yet even to identify as a larger community, do you have any advice or recommendations for those of us in the US, or who may be listening around the world in terms of moving forward and continuing to try to keep everyone safe, including our patients as well as healthcare providers?

Karim Fizazi: Well, one thing that was striking in the last day of the week, was really the solidarity between people in general, and amongst the medical community. For example, we have had an on-call for COVID patient surveys, and immediately dozens of doctors volunteered to do that, even if it's not necessarily a nice thing to come back to the hospital to stay at night, et cetera. And the same was true in the day for all COVID-19 services. There was really no issue to find doctors to take care of these patients, even if this is risky. And I think, of course, I mean, humanly it's just great. It's really telling us that what we're doing is important, and if we decided once, to become a doctor, it was not for nothing.

So we should keep that alive, we should also be very, again, practical, cautious, share experience, protect ourselves because it's not only important for us, but it's also important for the patients. Of course, use all the recommendations that we have at the moment in place regarding the use of masks. The alcoholic thing that we're using on our hands, and make sure everybody stays at home when they are not needed. I think all these things are very important to make sure the epidemic is as smooth as possible.

Alicia Morgans: Well, thank you for that. Thank you for your guidance, and we will be sure to check in with you in a few weeks as this situation continues to evolve over time. And I wished to all of you, your colleagues, your family, your patients, that you are all safe and as well as can be during this unprecedented time. Thank you so much, Dr. Fizazi.

Karim Fizazi: Thank you, Alicia, and the same to you, your patients and those you love. Take care.