Alicia Morgans: Hi, my name is Alicia Morgans and I'm an Associate Professor of Medicine and GU medical oncologist at Northwestern University in Chicago, Illinois. I am so thrilled to be able to speak today with a friend and colleague, Dr. Carmel Pezaro, who is a medical oncologist at Sheffield Teaching Hospitals in the UK. Thank you so much for being here with me today.

Carmel Pezaro: It's my pleasure.

Alicia Morgans: Wonderful. Well, Dr. Pezaro, we have been talking to folks around the world to really help round out our understanding as GU medical oncologists and urologists who are listening to understand what people are dealing with around the world in the setting of the COVID-19 pandemic. I think recognizing that this is going to be different depending on where we live and practice, and certainly depending on where things are temporarily with COVID-19, it's really helpful to hear different people's perspectives. Where are you right now, in Sheffield, in terms of dealing with COVID-19? How has this really affected your practice and your day-to-day?

Carmel Pezaro: I think like many, many people in many countries we're keeping on, keeping on at the moment. The UK has had pretty significant rates of coronavirus come through and lots of new cases still occurring daily. We've had significant deaths from coronavirus and a lot of our new cancer diagnoses, and cancer operations, and business as usual, has been paused because of coronavirus. Those are all facts and figures that I know people much more expert than me will have been talking about and people can access.

From my point of view as an oncologist, it's been tough. I think keeping going with cancer treatments, particularly for the population I look after, I mainly have a practice of prostate cancer treatment for men with advanced prostate cancer, so those are men who are already in the highest risk group for coronavirus. We've been working to try and keep cancer treatments going for men who were often in the middle of cancer treatments or continuing on cancer treatments and at the same time dramatically shift our practice to try and reduce their risk from this new terrible coronavirus situation.

At the same time, we've been juggling stresses in terms of what is coming in the hospital environment. We've been juggling staff absences. I think really it's been full time just trying to keep things going. At the same time, I think, for many of us, we've just been pretty fully occupied with some often quite unusual anxiety about worrying about where this is all going and what it's going to mean in terms of the next months of treatment.

Alicia Morgans: Absolutely. I think that the uncertainty of all of this has been very, very unsettling, certainly for clinicians who are trying to adapt their practices very, very rapidly and certainly care for very ill individuals, and for patients of course as well. Are you making efforts at Sheffield, not you personally necessarily, but the institution to really address and help care for the mental health of the clinicians who are trying to keep on keeping on and do so with others being out and in and certainly home stresses, as well as for patient mental health? Are there other efforts that are maybe happening or things that are coming down the line that may be helpful in all of this?

Carmel Pezaro: Yeah, there are efforts. I think the hospital administrative staff have been amazing. They've put in place some really good communication pipelines that have really helped because I think one of the anxieties is about the uncertainty. Having information is really important in this time of constant change and uncertainty. There have absolutely been resources that have been made available. I don't know the uptake of those. Well, I will speak personally. Sometimes I think we're just busy doing things and the thing that would often help is actually talking to others, but of course, at the moment, we're struggling to do that with the kind of personal connection that we might like because that's not part of the personal distancing message that's coming through. I think isolation has been hard.

Likewise, I think our patients have been very much battling with the fact that everything that we didn't even know that we cherished as normal has suddenly been taken away from them. Many people have been told that because of their vulnerabilities, they should be very sheltered from other people. That often means actually suddenly staying within the confines of their own property, but for months. That's been really difficult. People are frightened and people feel alone. I think those things are all hard. There are supports that are definitely available, but I also think it's very expected that this is going to have a really big psychological impact on everyone.

Alicia Morgans: Well, as you see things evolving, have you gotten to a point where the enormous tide of the initial infections are starting to settle down, or are you still in the height of really trying to deal each day with high levels of potential infection?

Carmel Pezaro: Our levels are starting to drop. We hope we've seen the peak and that things are settling back down. We're now starting to talk about the whole next wave of change and what that might start to look like in terms of whatever this new normal is. Again, there's a lot of uncertainty about what that might mean, but yes, we hope we're over the peak.

Alicia Morgans: That is definitely encouraging, but it brings to mind, like you said, certainly the next wave, but also what our next normal is going to be. What is the day-to-day going to be like in clinic knowing that COVID-19 at some level is going to be in the community perhaps? We still need to treat the cancer that we know patients have today, not just fear what they might get in terms of COVID in the future. What steps are you and the team taking to move into this next phase where you have to, in many ways, continue to treat the cancer knowing the risks that may still exist at some level?

Carmel Pezaro: We did a lot of work early on within our own teams and then also benchmarking against other teams, certainly nationally, looking at some pretty sobering, serious considerations of the data behind the treatments that we use. That was very confronting because we spend a lot of time learning data and believing in the treatments that we offer people. Then when you come back with a very dry approach and look at the incremental benefits of some of the treatments, I think it gives you pause about whether we are offering treatments that have relatively small incremental benefits and whether those treatments can still be justified in the setting of much higher risks.

We spent a lot of time looking at that early on and also thinking about priorities of treatments if we got to a point that we actually couldn't deliver all of the treatments. Thankfully, it hasn't come to that because the wave wasn't as high as we had feared. Now, in terms of the new normal, there's been a huge change in our work practice. Whereas before we were very wedded to an old school style of seeing almost everyone in person in clinics, we've now gone almost wholesale to doing consults by telephone. Some of my colleagues are doing video consults. I don't know if it's me who's the Luddite, or whether I'm trying to protect patients from trying to get on video conferences, but we tend to stick to telephone rather than video communication for our consults. We are now doing that for everything, including new patient consultations, which is a really interesting situation. Sometimes it means that we're going against what we've believed in the past, that we shouldn't be trying to break bad news over the telephone. Now we're being forced to break news over the telephone because actually the alternative is that we bring someone in and they're hidden behind a mask, and we're hidden behind a mask. They can't have a support person in the room with them.

There's been a huge change in practice in terms of how we deliver the care. We still are trying to keep care going and, for people on treatment, we're very much trying to keep those treatments going where appropriate, but we're doing the blood tests out locally in the community. That may mean a district nurse actually going into someone's home and taking the blood tests for them. Then we're doing telephone consults and then, if it's an oral cancer treatment, getting that delivered out to the patient's home. I mean that model of care in some ways is very reasonable in that it actually certainly takes a lot of onus off the patient in terms of time spent traveling, and trying to find a car park and things.

It has meant that there's been a change in the administrative load and organizing all of those things. Our fabulous nurse specialists are spending a lot of time organizing to get those blood tests organized at the patient's home, for example. The question then is whether we can deliver some kind of a hybrid going forward so that we can still deliver a lot of the care without people having to come into hospital, but at the same time trying to get a system back where we can see people when it would be much better to have that face-to-face conversation because actually there is something that's lost when you do everything by telephone. I believe there is. I think that personal connection is hard to deliver as a sympathetic voice over a telephone.

Alicia Morgans: I completely agree with that. I think you make a really excellent point about, particularly in the setting of breaking news, we as oncologists never really broke bad news over the telephone or tried to limit that as much as possible so that we could have that human connection in a setting of things that nobody wants to say and nobody wants to hear. When we are forced to do that over the telephone, at least we can maybe take comfort in that the patient may not be alone where he or she might be alone if we're breaking bad news in the clinic at this point, given the restrictions on having visitors. Very, very different than what we would normally do.

Just to think for a moment about treatment choice, and you definitely alluded to some of this, but I think the UK is in a situation that's a little bit different than the US in that certain drugs are approved in certain settings that may or may not be approved or at least paid for by the National Health Service in the UK where they may be paid for in the US.

Just to give an example, and I guess to put you on the spot, and certainly, you don't have to answer this if you don't feel comfortable, but when we're facing patients with metastatic hormone-sensitive disease in the US and in other places like Canada and others, we could potentially choose to use an oral AR targeted agent in that setting rather than use chemotherapy, which in a normal situation we would in most cases have a very frank discussion with him patients and talk about the pros and the cons of each method. Really patients can help make those choices very effectively, but in the setting of COVID-19, many of us have switched to really trying to limit immunosuppressive agents right in the midst of the height of the pandemic and had been choosing AR targeted agents.

This may shift as we go move again into a new normal where we have maybe a smoldering level of COVID-19 in the population, but not the large wave that we initially were facing, but in the UK and in other places, there may not have been the same opportunity for choice. In that setting, you might've been thinking about chemo hormonal therapy or ADT alone. How were you making that decision? Perhaps maybe you didn't have to make that choice. Maybe you just delayed the chemotherapy. What were your thoughts when you were facing chemotherapy in the setting of COVID-19?

Carmel Pezaro: Yeah, they were really hard thoughts and the situation has actually changed just recently. Certainly, we were looking at patients who are currently receiving chemotherapy with docetaxel and thinking about had the patients already achieved a really good PSA decline, and were they really therefore in a really good outcome group and should we continue to our plan six cycles, or should we actually encourage stopping sooner to try and balance risk against that benefit that people had already achieved. We were certainly trying to delay, to get a sense of what was happening, because initially, again, the uncertainty about what was coming made it very difficult. There were certain patients who we felt very strongly the benefit was still strongly in favor of getting started on treatment. For those patients, we had very frank and uncomfortable discussions about the risk of coronavirus and how very severe that could potentially be and that we were there for risking, potentially, a life-threatening infection compared to something we were trying to do to add benefit with a timeframe of years for their prostate cancer.

For some people, we felt that actually the benefit was modest and that the risk was much higher than it would previously have been considered and that actually those numbers didn't stack up in favor of supporting or recommending upfront docetaxel. We've just had an announcement that actually there will now be interim access to an oral targeted agent. We'll have access to enzalutamide for men who have been recently diagnosed with hormone-sensitive prostate cancer. For men who are not suitable for enzalutamide, we then will have the choice of abiraterone. Actually the situation has changed and I think that's a really welcomed change because, as you say, those oral agents offer excellent treatment for prostate cancer, but with not nearly the immunosuppressive risk of docetaxel.

Alicia Morgans: Well, that's an exciting thing to learn about. I'm glad that you have that opportunity. I'm sorry for the conversations you've had and the decisions you've had to make, but, as we all can see, things are evolving both in terms of COVID-19 and certainly, they're evolving in the NHS hopefully only for the better. As we wrap up, are there any parting messages you'd like to leave the listeners with as you're facing COVID-19 in your clinical practice?

Carmel Pezaro: Yeah, I think I rather really have three things that I would want to say. The first thing is I want to quote someone else. There was an oncologist by the name of Lucy Gossage who wrote in The Guardian in March. She wrote about the emotional consequences of COVID-19 on healthcare professionals who are going to be making difficult and life-changing treatment decisions without good evidence. I think that was, for me, one of the most powerful messages that I read around coronavirus. I appreciate that lots of people have been giving opinions about treatment, but I really appreciated that she thought about that impact on people. I think it's really relevant.

I think the next thing I would want to say is that, for me, the fact that in some areas coronavirus has been described as a battle reminds me how little I like battle as a metaphor in general and how little I like battle as a metaphor in cancer. I think it is an opportunity perhaps for us to stand back and think about the words that we use and why we feel that cancer is something that we have to describe as this terrible war that we wage because I don't think that that gives people an opportunity to actually see in context with all of the other things that occur and these unexpected things that we never even imagined coronavirus was going to come along.

I think it becomes difficult if we've encouraged people to see cancer as the most important thing that they're fighting against. Then suddenly we're telling them that it's less important than this new problem because that actually shapes the entire foundation that we're trying to work on. For me, it's really reminded me that that cancer is not a battle. It's a condition that requires treatment and it requires management amongst everything else that's going on.

I think the other thing, the last thing that I've been thinking a lot about, is that while I think there have been some really positive things that have occurred in terms of adjustments and change, I think for me this situation has also highlighted some of the challenges and perhaps gaps in the way I practice anyway. I've been thinking a lot about how we plan, and discuss, and acknowledge that death is something that is inevitable for all of us and something that for many patients is the inevitable outcome of their cancer.

I think we're so busy fighting this battle, I'm not sure that we spend enough time, or in fact, I'm quite sure that I don't spend enough time, thinking about how to help people recognize that there will be an end and that there are some choices that can be made around that. I'm hoping that out the other side of coronavirus, I can try and think about how we can, not remove hope, but at the same time acknowledge that death is not something that we have to pretend only happens to other people. We can actually plan and prepare for that when it happens, even while we're trying to treat and delay it from occurring.

Alicia Morgans: I think those are all very good messages indeed and good reminders for all of us as we face uncertainty and certainly try to make the plans that we can, not always knowing which way things are going to fall. That is reality. That is life. I appreciate you reminding all of us as we try to move forward. Thank you so much for your time today and for sharing your thoughts. I hope that you stay safe and that things continue to improve where you are for you, your patients, and all those around you. Take care.

Carmel Pezaro: Thank you. I wish the same to you.