Alicia Morgans: Hi, this is Alicia Morgans, GU medical oncologist and Associate Professor of Medicine at Northwestern University and I am so grateful to have here with me today. Dr. Hala Borno who is a GU medical oncologist at the University of California San Francisco, UCSF. Thank you so much for being here with us today, Hala.

Hala Borno: Happy to be here with you.

Alicia Morgans: Well thank you. We are just trying to survey essentially people who are dealing with the COVID-19 crisis, clinicians who are dealing with this across the country and across the globe, to get a better understanding of what different institutions, what different folks are seeing on a day-to-day basis. And we'd love to hear your perspective on what you're experiencing in San Francisco. What's going on, how has your practice changed and how has your day to day changed as you care for GU oncology patients?

Hala Borno: Absolutely. I would definitely say that this has been a really scary time to be an oncologist. I think in general oncologists are worried about creating risk for patients with some of our therapies that have toxicities and some of our therapies that make patients more susceptible to infections. And I think when you're thinking about susceptibility to infection in the context of COVID, it's really a scary time and it requires us to be a lot more thoughtful about what needs to happen now for our patients and what things can happen later in the context of a safer global environment.

Alicia Morgans: Is it affecting the choices you're making with treatment? For example, with your prostate cancer patients or maybe some of your testicular cancer patients or other patients as you're seeing them in clinic when you see them in person. If that does happen anymore on a day-to-day basis.

Hala Borno: I think that COVID is affecting all aspects of clinical care. It's affecting the way that we interact with patients. It's affecting the treatments we're making, the diagnostics that we're collecting, really all aspects of clinic, and a lot of it is because there's an imperative for risk reduction. And that imperative for risk reduction requires for things that used to be more high touch to be less so right now. And so for example, typically patients will come in for a routine clinical visit will be in person and we'll interact with the patient, we'll do a physical exam and may or may not receive a drug during that clinical visit. And by and large, we've shifted most clinical encounters to be remote-based, to use telemedicine, whether it be Zoom, WebEx, or the telephone to touch base with the patient, make sure they're fine, to collect the clinical outcomes that we're interested in, but to make sure that they're safe at home and to reduce their risk of going into an environment where they could potentially be exposed to the virus. And so clinical care is absolutely impacted.

And also the diagnostic piece is critical. Anything that we can delay in terms of having patients come in for scans, come in for assessments, anything that can be safely delayed and isn't vitally necessary at this juncture we are doing, again for that imperative of risk reduction. When it comes to treatment as well, if I have a patient for whom I was thinking of starting some sort of immunosuppressive therapy or even immune therapy that I can safely delay it, I do so because I worry about the risk of creating a situation where they may be more compromised and susceptible to infection in the context of a surging outbreak. And we know from looking at New York and we know from looking at our own statistics of the rising rates of positive COVID tests in California, which is where I practice, that the outbreak is still surging and we will see more cases and so the environment today is still a higher risk one.

Alicia Morgans: So it's so interesting that you really bring up the diagnostic end of things because that is a piece I'm still struggling with a little bit. There are many things that we can do without a patient actually leaving his home or her home if it's a bladder cancer patient for example. But I can't do labs from the house and I can't do imaging from the house. So how are you making choices about lab work and about imaging or your patients knowing that there's not a right answer here? This is something that I'm struggling with still on a day-to-day basis for the patients that I'm going to see tomorrow even I'm still struggling. What are the factors that you're considering as you're thinking about putting off or delaying the lab work and the imaging testing that we are so reliant on in medical oncology?

Hala Borno: It's a challenge. I think that we are being forced today to reassess the frequency of the data that we collect to have a good practice of safety monitoring. We're really forced to reassess the need to potentially get monthly labs versus every six-week labs. That difference of four versus six weeks could be very important for a patient who may or may not be entering an environment that is at much higher risk if they go at four versus six. And so for me, while there is no right answer, I think it's a constant risk/benefits discussion and it really has a lot to do with the cadence in the symptoms, the cadence of the disease and the symptoms a patient is experiencing.

If I know a patient's symptoms and the pace of their disease are progressing rapidly, that's a scenario where I say the risks of their disease are so great that I am willing to potentially have them be an environment where there is a risk of infection. But if the pace of the disease is more indolent or stable and the patient's symptoms are stable, then what I've been telling my patients is I just want you to be home and bored. And if you're bored at home, then I'm happy because that means you're well, and at the end of the day, that's the most important thing for our patients right now is for them to be well and safe and sheltered and to minimize their risk.

And this question of risk is, it's not in one direction. We've been talking a lot about healthcare workers' risk and us being on the front lines and interacting with patients and I think that that's also something that should be attended to that while we are used to seeing our patients, sharing a space with them, and developing an intimate encounter because we're dealing with such important and difficult issues. This is not the time for that because it's important to protect ourselves and it's important to protect our patients from what's going on in the larger context.

Alicia Morgans: I completely agree and I am heartened to see that our community has moved in the direction of trying to deliver more telehealth and to try to do as much as we can via web or by phone. But I wonder, I know you have a particular interest in racial and ethnic minority patients. And I wonder if we will see that there ends up being an even greater disparity in care delivery for those populations in particular given the changes that we have to make. I don't know that there's an answer to this yet, but I wonder if you've thought about that.

Hala Borno: I think that's a great question. What are the implications of this forced redesign of the way that we deliver care? And this redesign does not only apply to conventional clinical care, but it also applies to clinical trials and clinical trial visits. And I think, my personal opinion, and I think time will tell, is that this actually may make clinical care and clinical trials more inclusive and accessible. It certainly can help obviate the need for excessive travel to specialized centers, which tend to be in more urban contexts. So it might help relieve some of the disparity associated between rural settings and urban settings.

And then this question of racial-ethnic minorities, I mean I think we know that racial-ethnic minorities also rely on information technology, use the internet to access health information. And so being able to use the internet to access clinical care seems like a natural extension of that. So my hypothesis is that deploying on a larger scale and making it the convention that clinical care and clinical trial visits are deployed through digital health would actually improve and reduce disparities that we've observed historically.

Alicia Morgans: But certainly something we should think about studying because as I think about it, at least in my practice, a lot of the trust that goes into agreeing to participate in a clinical trial comes from that in-person interaction and that engagement as human-to-human. And if that is lost, then I wonder if some of the trust and some of the willingness to engage in a clinical trial may be lost as well. And I think your hypothesis is a great one and I hope that's the case, but I also hope that you and your colleagues continue to study these kinds of things because I think that it's an interesting question to answer as we go through this really unprecedented situation.

Hala Borno: You're absolutely right and I think it is critical to think through the relationship between a medical oncologist patient when we're leveraging these types of tools to communicate and how that may inform these types of decisions that patients make, whether or not to enroll in trials. I think that that is really an important thing to think through and to study.

Alicia Morgans: Wonderful. Well, lots of work for you to do and lots of work for all of us to do as we move in the direction of trying to continue to provide optimal clinical care in a way that's safe, that keeps our patients safe, that keeps our colleagues, our fellow clinicians safe, and hopefully does not let anything falter in terms of disease control and supportive management for our men and women who suffer from GU cancers. Thank you so much for your time and your expertise today, Dr. Borno.

Hala Borno: Thank you.