During the COVID-19 pandemic, The ASCO Post will be interviewing oncologists on how they and their centers are dealing with the crisis. Here, we speak with Alexander Melamed, MD, MPH, a gynecologic oncologist and Assistant Professor of Obstetrics & Gynecology at NewYork-Presbyterian/Columbia University Medical Center, New York. He spoke about limited resources to save lives, how labor/delivery cannot stop during a pandemic, and the power of strong leadership.
Alexander Melamed, MD, MPH
A Health-Care System in Flux
New York state has had more coronavirus cases than any country in the world. What has been the biggest impact at your institution?
There are two ways in which people are being impacted. First, resources have become scarce because the health system is not built for this. The hospital is having to divert a huge amount of resources to save people’s lives who are very sick from COVID-19. Operating rooms (ORs) have been turned into intensive care units (ICUs), and many OR personnel have been redeployed. Second, every time you bring a patient into contact with the health-care system, you’re risking an infection.
Something as simple as a posttreatment computed tomography scan for a patient who has finished adjuvant chemotherapy becomes a question: Now I think, “can this wait 2 months?” If the imaging is unlikely to change what I do and every interaction with the health-care system carries significant risk, there’s no way I’m bringing this patient to the hospital for that.
There’s been a huge change in the way everything we do for patients with cancer is being evaluated. We’re doing telemedicine visits whenever we can. We’re bringing in people for exams sparingly. We’re still treating patients, but we definitely have a very, very different approach.
Are you also limiting surgical opportunities?
Our thinking about surgery has also changed dramatically because there are few ORs
available. For example, a patient with advanced-stage ovarian cancer is unlikely to receive primary cytoreductive surgery right now. For low-risk endometrial cancers, which I would usually treat with hysterectomy, I recently used an intrauterine device, which is a fertility-sparing way of treating the disease. I’d almost never do that for a postmenopausal woman normally, but now it’s a way of not utilizing our scarce OR resources. There’s somebody who potentially needs that OR more: someone who has cancer for which there is no nonsurgical option or someone with appendicitis or a perforated bowel, for example.
“Our thinking about surgery has changed dramatically. A patient with advanced-stage ovarian cancer is unlikely to receive primary cytoreductive surgery right now.”— Alexander Melamed, MD, MPH
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Reasonable Standards of Care
Are there certain guidelines you’re following right now, or are you going on a case-by-case basis and by the health of the individual patient?
For me as a gynecologic oncologist, the Society of Gynecologic Oncology (SGO) has been an important resource. The Society has put on webinars and released statements about treating patients with gynecologic cancers in COVID-19–burdened regions. Within my department, we have convened to determine what conditions can wait and what conditions cannot. We’ve tried to figure out reasonable standards of care under these extraordinary circumstances. We wouldn’t usually use progesterone therapy as a primary treatment of a postmenopausal woman’s endometrial cancer, for example, but there are data indicating it works in other settings, so that seems acceptable now.
Several randomized trials have suggested that neoadjuvant chemotherapy may be just as effective as primary debulking surgery for advanced ovarian cancer,1 so for me, that’s an easy decision, but other cases are judgment calls. If a woman comes in with an ovarian mass, it could be cancer, although most of the time it’s not. Can she wait for surgery? It depends on how suspicious the mass appears to be and other risk factors. We discuss it as colleagues and try to involve our patients in shared decision-making as well. In the end, we also have to get approval to use OR resources; it’s not just our decision anymore because the hospital’s capacity to perform surgery is so limited right now.
You mentioned pushing back routine surveillance a couple months, but do you have a timeline for some of these delayed surgeries?
It’s all based on the situation on the ground. In general, we are able to do operations that are needed urgently, but for everything else, we’re continually figuring it out. If you say, ‘This woman’s life is at stake, and we have to perform surgery,’ then it will be a go. But when can I start doing primary debulking surgery for ovarian cancer, or booking hysterectomies for low-grade endometrial cancer again? Two weeks? One month? It depends on who you ask. I think New York will have to be on the other side of the epidemic curve before things really start returning to normal [in terms of surgery].
A New Normal?
What’s the anxiety level for you and your colleagues at Columbia right now?
I can only speak for my department, obstetrics and gynecology, but I think people are handling it remarkably well. I see people really stepping up. A lot of us have been redeployed and are no longer doing our normal jobs. For instance, I’m a gynecologic oncologist, but I’m delivering babies this week because labor and delivery can’t stop during a pandemic. It’s an honor to be able to lend a hand, because you know your colleagues are out there putting their lives at risk.
Our department has a daily phone call that includes 150 people; it is led by our Chair, Mary D’Alton, MD, and we get all up-to-date information. We talk about what’s working, what’s not working, and how we can continue to produce research that’s going to help others. Researchers in our department just published an important case series of pregnant women with COVID-19, for example, so even in the middle of an epidemic, we’re still looking for opportunities to conduct research and generate evidence.
The colleagues I worry about most are those who have and care for older parents. My parents are across the country. I worry about getting my wife sick, but she’s also a gynecologic oncologist, so she might get me sick, too. I have a daughter, and you always worry about your kids. There are doctors in ICUs in New York who are fighting for their lives, so it’s concerning. Fortunately, I have the protective equipment I need to do my job as safely as possible. Members of my department ask all the time whether I have what I need, so I feel people are looking out for me and enabling me to be a doctor. This may be a special opportunity to be a doctor in a way that you’re not always asked to be.
Benefits of Strong Leadership
Do you have any advice for colleagues at other institutions who have not had the same influx of patients infected with COVID-19 yet?
One thing I’ve benefited from here is having strong leadership. People are communicative and let you know what’s going on. Leadership is always important, of course, but these times are the ones when it matters even more. The situation is changing faster than anyone anticipated. I think this is a moment for the people who are in charge to shine—to plan ahead, take control, and communicate clearly. Speaking as a junior person in my department, when you have a strong leader, it’s inspiring. Even though there is chaos, it doesn’t feel like it.
When you drive through Times Square and there is not a single person on the street, you know something is deeply wrong. But when there is a plan to address problems as they arise, then you don’t feel quite so lost. You feel like you’re dealing with it. And then you just keep dealing with it, and eventually it’s going to have to get better.
DISCLOSURE: Dr. Melamed reported no conflicts of interest.
REFERENCE
1. Knisely AT, St. Clair CM, Hou JY, et al: Trends in median survival and upfront treatment among women with advanced ovarian cancer in the United States: 2004–2016. 2020 Society of Gynecologic Oncology Annual Meeting. Abstract 175. Presented March 28, 2020.
