Oncologists on the Front Lines of COVID‑19

A Conversation With John Cole, MD

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Coronavirus disease 2019 (COVID-19) is dramatically affecting health-care systems. This is the first in a series of interviews The ASCO Post will conduct with oncologists, to learn what they and their cancer centers are doing to deal with the crisis. In this article, we talk with John Cole, MD, a breast cancer specialist and Head of Clinical Oncology Research at Ochsner Health in New Orleans, Louisiana’s largest nonprofit health-care system.

John Cole, MD

John Cole, MD

Protecting Patients and Health-Care Professionals

What are you and your colleagues at Ochsner doing to protect yourselves and your patients from coronavirus?

This virus is definitely bad business, and we are expecting things to get worse. We have lots of patients already on ventilators at many of our hospitals. We believe the big issue for us is the prudent use of supplies. We are expecting this to last over weeks or months, so we are trying not to overuse masks, gloves, gowns and to husband our resources the best we can. Although we can’t have all our staff walking around the hospital in N95 masks, if someone is exposed and not symptomatic, he or she is required to wear one to protect himself/herself and his/her patients. Every day, before staff members come through the door, we check their temperature; and yes, we’ve had to send some home.

Securing Additional Resources

Are you concerned about shortages of hospital beds and ventilators?

There’s been an incredible amount of effort put toward securing additional resources, with the thought that we might need them in a pinch. When all this started, Ochsner made contingency plans. For one thing, we opened a number of brand-new units with negative pressure. We are expecting to open up 100 new ICU beds at our main hospital in the coming weeks.

“There’s been an incredible amount of effort put toward securing additional resources, with the thought that we might need them in a pinch.”
— John Cole, MD

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The other thing we are doing is identifying physicians who are willing to step in and serve more or less as hospitalists for critically ill patients. We are developing a way to have those physicians manage patients on a day-to-day basis under the supervision of a critical care specialist. We feel we can do this because, to some extent, the management of critically ill patients is algorithmic; once the patient goes on a ventilator, it’s largely a matter of adjusting settings, monitoring blood work, and so forth. A lot of that work is just keeping the numbers in line and moving forward, and we hope to give our intensivists some help with this approach.

Emotional Barometer

All things considered, what’s the anxiety level among health-care workers at Ochsner?

The type of anxiety you feel depends on who you are. For the Ochsner leadership—those of us charged with leading Ochsner and making things happen—our anxiety is largely about getting overwhelmed with cases and the logistics of caring for them. For the rank and file, I think the concern is about becoming infected. A medical assistant, for example, didn’t really sign up for that. However, we physicians basically signed up to take care of patients, even if it puts us at risk. I think there’s a different contract there.

Point-of-Care Testing

Has your testing capability at Ochsner improved over the past few weeks?

Yes. We are now doing polymerase chain reaction (PCR) testing in our own lab and are working on point-of-care testing. Prior to this, we did most of our testing through the Mayo Clinic, because the state’s process was slow and cumbersome. Through Mayo (and now with our own testing), we can basically make our own rules in terms of who undergoes tested (while still following guidelines). This is important because we can test health-care personnel who might not otherwise satisfy the stringent criteria of the state of Louisiana. We really need to know if someone has the virus or not. It may take 1 to 2 days to get the result; if the person is negative, he or she can come back to work; otherwise, he or she is quarantined for at least 14 days.

Command Central

Have you set up some type of command center at Ochsner?

Yes. Our top administration officials, physican leaders, and infectious disease team basically are responsible for daily updates. We have anywhere from one to five video conferences daily to update everyone. At 5:30 PM every day, the hospital leadership receives a summary of the day’s events. Because this is such a fluid situation, our plans for one day may have to change for the next. We are all learning from our personal experiences and are creating commonality in how to approach things.

“If we keep our patients’ safety and, right behind that, the oncology team’s safety, as the two most important aims, decisions flowing from that will be the right ones.”
— John Cole, MD

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COVID-19 and Cancer

How do you handle patients who show up with symptoms of COVID-19? And what if they also have cancer?

From the perspective of everyday care, when a patient presents to the hospital with symptoms suggestive of COVID-19, we admit that patient to a dedicated internal medicine area where we can cohort these patients. If they are oncology patients, our approach depends on whether they actually need to meet with an oncologist. If they do, only the staff oncologist—not fellows or house staff—goes into the exam room. For patients who do not really need to see the oncologist, we can review charts, blood tests, and so forth and do virtual consults. We are trying to keep contact with health-care providers to a bare minimum.

How are you managing routine cancer care?

We are postponing any type of routine follow-up, such as yearly mammograms. If the patient is coming back for interval surveillance after treatment, the treating oncologist determines whether a delay in imaging, for example, would potentially harm the patient; if not, that is also delayed. If the patient needs imaging to monitor tumor response to treatment, that’s still being done. Obviously, tumor resections and placement of ports are going forward as planned. We are trying to reduce the volume in the system wherever we can.

Have there been any changes for patients requiring chemotherapy infusions?

We are approaching that in two ways. We are doing some virtual (video) visits for patients who are receiving chemotherapy who are doing okay; they undergo blood work, then have a virtual visit with the oncology provider, and then go straight to chemotherapy. We are also no longer allowing visitors/companions. We’re trying to minimize the touchpoints wherever we can. We are adding remote monitoring capabilities (Ochsner Chemo Care Companion).

Clinical Trials

How has COVID-19 impacted your clinical trials program?

We have looked to our research bases (eg, the National Cancer Institute Community Oncology Research Program) for guidance, but we also believe the right thing to do is what’s right for an individual patient. With that as our central tenet, we are looking at all interactions among patients, investigators, nurses, and making decisions based on them. If a patient needs treatment or labs for safety reasons, for example, that has to happen. If the patient is, for example, receiving an oral agent and does not absolutely have to come here (even though the trial protocol calls for it), we are converting that to a video visit. We’re taking steps to keep our trial patients out of harm’s way.

“We’re taking steps to keep our trial patients out of harm’s way.”
— John Cole, MD

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Words to the Wise

Finally, do you have any advice for community oncologists who perhaps don’t work in a large cancer center?

What we’ve tried to do, and what I think helps, is to have a plan and then develop a clear message around that plan for your patients and also for your staff. Everyone needs to be reading off the same page. If we keep our patients’ safety and, right behind that, the oncology team’s safety, as the two most important aims, decisions flowing from that will be the right ones. 

DISCLOSURE: Dr. Cole reported no conflicts of interest.