Cancer Update September 2020 by ChristianaCare

SE P T E MBE R 20 20 Issue No . 41

cancer update

We wonâ&#x20AC;&#x2122;t stop for Coronavirus.

IN THIS ISSUE

cancer update

Director’s Corner Nicholas J. Petrelli, M.D., Bank of America endowed medical director of the ChristianaCare Helen F. Graham Cancer Center & Research Institute, shares his perspective on virtual tumor conferences

t the Helen F. Graham Cancer Center & Research Institute, our team has been spot-on in protecting our patients and caregivers throughout the COVID-19 pandemic, because we know that cancer does not stop for any virus. We also know the best cancer care is multidisciplinary with an entire cancer care team collaborating in the best interests of each patient. At our Tuesday thoracic tumor conferences, for example, picture the conversation with three medical oncologists, two thoracic surgeons, two interventional pulmonologists, the clinical trials nurse and the radiation oncologist all in the same room. It is classic multidisciplinary.

For now, as long as social distancing remains the norm, multidisciplinary care often means virtual care, and for the most part, our tumor conferences have continued their important contribution, virtually. I’m reminded of a comment made by Cliff Hudis, M.D., FACP, chief executive officer of the American Society of Clinical Oncology (ASCO) following the June ASCO virtual annual meeting: “If we were robots, and our job was to vacuum up all of the information in the most efficient way possible, the virtual meeting gets us in that direction pretty successfully,” Hudis said. “But … what makes the ASCO meeting useful to the world … is you bump

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Helen F. Graham Cancer Center & Research Institute

Message from Dr. Petrelli

We don’t stop for coronavirus!

Some cancer surgeries just won’t wait

Staying connected with telemedicine

12 Darrel’s choice during COVID-19 14 Patients stay strong on clinical trials 17 New safety protocols

into people, you sit down, and over a cup of coffee, you talk about some ideas you have. Out of those happenstance and planned meetings, new collaborations are born.” Over the years, I have seen this happen at our tumor conferences, although recently coffee and bagels were missing. (They will be back!) I’ve seen surgical residents draw attendings aside to talk about a patient issue. I’ve seen attendings confer about writing a manuscript after an interesting case presentation, while others talk privately with our genetic counselors about a mutual patient. Often new projects arise from small groups who stay behind after the conference, such as the idea of locating a primary care physician at the Cancer Center. This is perhaps the only project of its kind in the country that will soon become a reality here.

There is an esprit de corps at tumor conferences with everyone present in the same room. It comes from having the ability to look someone in the eye and ask, “What are your thoughts on this?” when they can’t step away from the screen or mute themselves. Virtual medicine will continue in some form, with benefits, no doubt, but I can’t wait to get back to a capacity-filled conference room to converse in person with colleagues in ways that go beyond medicine. Frankly, in our environment we need that. Until then, will the doctor with the kids and the dog in the background please mute themselves!

“There is an esprit de corps at tumor conferences with everyone present in the same room.”

Cancer Update | September 2020

Cancer doesn’t stop for a virus and

NEITHER DO WE

When the World Health Organization announced the COVID-19 pandemic in March, the Helen F. Graham Cancer Center & Research Institute mobilized in many ways to ensure patients would continue to receive the same exceptional care they have come to expect. Specialized inpatient care has continued on 6E Oncology and the Bone Marrow Transplant Unit at Christiana Hospital, now at full capacity. All patients are screened for COVID-19 prior to coming on the unit where oncology nurses follow evidence-based infection protection protocols to guard against viral transmission. Throughout the pandemic, as evolving circumstances called for rapid decisionmaking, our clinical teams rose to the challenge of providing the highest level of care to our most vulnerable patients. “Our staff did a phenomenal job keeping our patients safe and working together through something none of us had ever experienced,” said Nurse Manager Courtney Crannell, DNP, MSN, OCN, NE-BC. “At first, guidelines and protocols were being updated every few hours, but our nursing staff remained flexible and focused on providing the absolute best care for our patients.”

Helen F. Graham Cancer Center & Research Institute

Cancer treatments can weaken the immune system and make our patients more susceptible to COVID-19 infection and mortality. At the Graham Cancer Center, we are taking every precaution to keep patients and staff safe inside. Telemedicine helps patients stay connected with their care teams from a distance, while screeners at the doors and safety protocols throughout reassure and protect those who do come in for treatments or imaging for evaluation. Despite the coronavirus, our Radiation Oncology teams have safely welcomed more than 100 patient visits a day, while our chemotherapy infusion suites have remained at 80% capacity. To keep everyone distanced from harm’s way, we ask our patients to come alone to their appointments unless they require special assistance. Several cancer surgeries initially were delayed without harm, but others proceeded, including for cancers of the pancreas, liver, lung and kidney. Our Radiology Department was right on top of every imaging request for CTs or PET scans. Our clinician investigators and research nurses continued to enroll patients in clinical trials even while many cancer centers across the country scaled back accruals. In standing up to the coronavirus, much of how we do things has changed, but what we do to provide exceptional cancer care has not.

Cancer Update | September 2020

Nationally, the American Society of Breast Surgeons is collecting information about the effect of COVID-19 delays in surgery. “We expect the analysis may show that treating patients with estrogen suppression for a few months prior to surgery is not only safe, but might result in some improved outcomes,” said Dr. Dickson-Witmer. “This, along with our new comfort with telemedicine, may alter practice in the future.”

It’s safer to get treatment

In the wake of the coronavirus, some cancer surgeries just won’t wait

ancer surgery is an essential component of cancer treatment. As COVID-19 patient numbers soared around the world, the Helen F. Graham Cancer Center & Research Institute followed best practices to ensure that patients who needed timely cancer surgery experienced no harmful treatment delays. “For some cancers, surgery that is delayed can become surgery that is dangerous in just a matter of weeks,” said Nicholas Petrelli, M.D., Bank of America endowed medical director. “The decision to operate under the extreme and unusual conditions created by the coronavirus was never a perfect one, but in every case, the decision was determined to be the best one for each patient.” Breast cancer patients, perhaps more than any other group, were impacted by the

necessary operating room restrictions. “More than 150 breast cancer patients experienced some disruption of the standard treatment course,” explained Diana DicksonWitmer, M.D., medical director of the ChristianaCare Breast Center. The team worked with a group at Harvard University using a 40-point scoring system to prioritize patients for urgent surgery and to determine whether others could safely be delayed. “Several of our receptorpositive patients, all of whom were on estrogen blocking pills during their delay, noticed a decrease in size of their cancers,” said Dr. Dickson-Witmer.

Lung cancer is the leading cause of death for both men and women in the United States. Both esophageal cancer and lung cancer are difficult to cure and delays in treatment can be catastrophic. Chief of Thoracic Surgery Charles Mulligan Jr., M.D., and his team believed that for many patients, the benefit of surgical treatment far outweighed the risks. “Our goal for our lung cancer and presumed lung cancer patients was to get them to definitive treatment by eight weeks from abnormal scan or four weeks from diagnosis,” said Dr. Mulligan. “Our goal for esophageal cancers was to get them to completion of tri-modality (chemoradiation followed by surgery) within six to eight weeks of completion of that neoadjuvant therapy.”

Chief of Surgical Oncology Joseph Bennett, M.D., has continued surgeries for aggressive cancers including pancreatic, liver and bile duct cancers and cancers that spread to other parts of the body. “We were able to safely delay some surgeries in our practice, but we remained very busy doing surgeries for more advanced cancers,” Dr. Bennett said

When in doubt, get it checked out Dr. Bennett has noticed a significant drop in the number of melanoma cases during the pandemic response — and that is causing him concern. “Three to five melanoma cases a week has dropped to none in the last few months,” he said. “I fear that people are delaying visits to

“Our goal for our lung cancer and presumed lung cancer patients was to get them to definitive treatment by eight weeks from abnormal scan or four weeks from diagnosis.” Charles Mulligan Jr., M.D., Chief of Thoracic Surgery

their dermatologists, which could ultimately lead to a rise in more advanced melanoma cases later.” Dr. Mulligan agrees that only time will tell what secondary deaths occur because of COVID-19. “How many people did not have cancers found early because of the fear of going for evaluation or inability to get studies done?” he asks.

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“More than 150 breast cancer patients experienced some disruption of the standard treatment course.” Diana Dickson-Witmer, M.D., Medical Director of the ChristianaCare Breast Center

Helen F. Graham Cancer Center & Research Institute

Cancer Update | September 2020

Telemedicine keeps patients and providers safe and connected during COVID-19

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Mindful of this concern, Dr. Mulligan and his team are collaborating with Radiology, Respiratory Therapy and Endoscopy to ensure that their cancer patients get the studies they need. Dr. Mulligan and lung specialist Gregory Masters, M.D., continue to see patients in person at their multidisciplinary clinic at the Graham Cancer Center. “Not only do we need to get a sense of the person as a patient to decide on appropriate management,” Dr. Mulligan said, “but that connection is so vital to helping patients cope when treating these difficult cancers.”

Connecting in new ways The hardest thing for everyone during the pandemic has been a lack of direct family interaction with patients and their providers. Families joining consults by phone is not the same as being physically present to ask questions and offer their support, vital

for cancer patients as they recover from surgery. Dr. Bennett recalls the patient who greeted him before her operation as though she was really seeing him for the first time. “Our initial consult happened over the phone, and the few times I met her in the office we were both wearing masks and social distancing,” he remembers. “When I walked in to greet her, she said, ‘Is that Dr. Bennett? You know I’ve never seen your face,’” he recalled. “I was about to do major surgery on this lady, and I realized with that encounter how important faceto-face contact is to the doctor-patient relationship. This has been a challenging time for all of us.”

elemedicine has opened new avenues for patients to connect with their cancer care team while staying physically apart to help slow the spread of the coronavirus. Roderick Wilson, 76, of Newark, enjoys his virtual nutrition counseling sessions almost as much as his wife, Maryanne, does. “We get lots of helpful tips and many good recipes to keep my calories up,” he said. Wilson is having trouble swallowing foods while undergoing chemotherapy and radiation treatments for tonsil cancer.

Maryanne does all the cooking for him and finds it comforting to know that Cancer Nutrition Specialist Tiffany Whary, RD, LDN, is just a phone call or Zoom visit away. “Since mid-March about 70% of our patient visits have been virtual ones,” Whary said. “Mr. Wilson was one of my first patients to try this approach, and although we had a bit of a learning curve, we have been able to continue our appointments virtually with success.” (CONTINUED ON NEXT PAGE)

If you have questions or concerns about your care during the COVID-19 pandemic, contact your doctor.

“When I walked in to greet her, she said, ‘Is that Dr. Bennett? You know I’ve never seen your face.’” Joseph Bennett, M.D., Chief of Surgical Oncology

Helen F. Graham Cancer Center & Research Institute

Cancer Update | September 2020

Roderick and Maryanne Wilson

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Virtual visits allow caregivers, patients and family members more time to spend in meaningful conversation. Throughout the pandemic, telemedicine has enhanced the Cancer Center’s ability to maintain safe ways to provide care, and patients and providers say they like the flexibility to have clinic visits from the comfort and privacy of their home or outside office — no long commutes, no crowded waiting rooms, the ability to have caregivers and family members present and more time to spend in meaningful conversation. “At present, all medical practices and departments are doing some type of virtual patient care,” said Practice Operations Director Chris DiMotta. “Our patients and providers have responded favorably, and I can see opportunities for us to continue to use these resources in the future.” Radiation Oncology went live with telemedicine for the majority of their consultations in mid-March.

“Our staff spent the necessary time and effort to help our patients get set up for virtual visits at home,” said Director Beverly Cusano, MHA, “We made sure our providers had what they needed to work remotely as well.” Patients who needed to come in for treatment or testing could do so safely, but even much of their radiation treatment planning could be done remotely, with medical physicists and dosimetrists accessing computer-planning models together while working safely apart at home. “Our medical physicists and residents have created a staggered after-clinic-hours schedule to maintain the performance of our treatment machines to ensure the highest quality standards,” said Firas Mourtada, MSE, Ph.D., D.ABR, chief of Clinical Physics at the Graham Cancer Center. “Even as some members of our team work virtually, we have others present onsite to support our patients

“Many have been facing similar existential threats with their diagnosis of cancer itself, and in some ways, have been preparing themselves mentally, emotionally and practically before COVID-19.” Psychologist Nicole Duffy, Ph.D.

Helen F. Graham Cancer Center & Research Institute

during their treatment.” With help from the ChristianaCare Telehealth Response Team, the Genetic Counseling and Cancer Risk Assessment program has stayed connected remotely with cancer patients, those with a family history of cancer and those needing prenatal genetic services. “We transitioned quickly to a HIPAA compliant audio and video platform to ensure our patients receive the care they need with limited exposure,” said Zohra AliKhan Catts, MS, LCGC, director of genetic counseling and gene testing. Psychologist Nicole Duffy, Ph.D., said she has seen a remarkable resiliency in her patients during an unsettling time. “Many have been facing similar existential threats with their diagnosis of cancer itself, and in some ways, have been preparing themselves mentally, emotionally and practically before COVID-19.” Psychological Oncology services have continued with about 95% virtual visits for individuals and support groups. The department also launched the Cancer & COVID-19 Support Group for patients coping

“Telemedicine provides a way for our multidisciplinary teams at the Cancer Center to extend a much broader reach as we move into the next phase with this pandemic.” Jon Strasser, M.D., Radiation Oncologist

with stressors related to the virus. “Telemedicine provides a way for our multidisciplinary teams at the Cancer Center to extend a much broader reach as we move into the next phase with this pandemic,” said Radiation Oncologist Jon Strasser, M.D. “I see us doing team telemedicine consults with patients further south with much more ease and expanding our influence and guidance to patients across the entire state.” Psychological Oncology services have continued with about 95% virtual visits for individuals and support groups.

“We transitioned quickly to a HIPAA compliant audio and video platform to ensure our patients receive the care they need with limited exposure.” Zohra Ali-Khan Catts, MS, LCGC, Director of Genetic Counseling and Gene Testing

Cancer Update | September 2020

DARREL’S CHOICE DURING COVID-19:

Stay at home or continue his cancer treatments In the weeks before Delawareans were advised to stay at home to protect against the coronavirus, Darrel Fleming, 54, of Felton, Delaware, expected to resume his chemotherapy treatments for abdominal cancer.

The Graham Cancer Center welcomes patients with nationally mandated virus control and prevention protocols.

Helen F. Graham Cancer Center & Research Institute

Since 2017, he had been coming for about four hours every other week to the infusion suite on the second floor of the Helen F. Graham Cancer Center & Research Institute. Darrel was forced to take a break from chemotherapy so that doctors could treat a blood clot that had developed in his lung. Afterwards, his doctor urged him to return to chemotherapy. “At first, I was afraid to go back because of what I had heard about the virus attacking the lungs, especially,” Darrel said. “I felt reassured when I learned about all the safety precautions they were taking at the Graham Cancer Center. After all, I trust them for my cancer care. I know they will do everything they can to protect me from being infected with COVID-19.” With nationally mandated virus control and prevention protocols in place throughout the Cancer Center, ChristianaCare Hematology Oncology has continued to provide chemotherapy for 60 to 70 patients a day. Whenever possible, clinic visits have transformed into virtual ones and non-urgent labs or maintenance such as chemotherapy port flushes are postponed. However, Darrel’s potentially life-extending chemotherapy could no longer be delayed. “Kudos to our infusion suite nursing staff who have worked tirelessly to make our patients feel safe and comfortable,” said Clinical Practice Coordinator Jordan Polifroni-Williams, BSN, RN, OCN. “Even though the room is set up differently with fewer chairs and no visitors, we have tried to keep the routine as normal as possible, while protecting those patients who really need to be here.”

Some nursing computer stations are now on wheels and the room is arranged in sections so that the same team cares for the same patients every time they come in for treatment. Patients and staff like the new setup that Polifroni-Williams said will probably become permanent. Clinical Leader Nicole Stipo, MSN, APRNCNP, who supervises the Department of Gynecologic Oncology’s infusion service, now conducts all her chemotherapy teaching sessions virtually. “Besides the desire to stay safe from the virus, many of our patients want to avoid coming to the office when possible, particularly those who are elderly or who may have a long drive or other transportation concerns,” she said. Nevertheless, the gynecological oncology infusion suite has operated at near capacity throughout the pandemic. “Anxiety levels are higher for all of us,” she said, “but even in this time of social distancing, our nurses have found ways to connect with patients who need that extra level of comfort and support.” That is why, when faced with the need to continue treatment, Darrel Fleming chose to make the hour-long trip to the Cancer Center. “I’ll be making this trip for the rest of my life,” he said. “There are facilities closer to me where I could get treatment, but the wonderful people here make all the difference. Each and every one is like family to me.”

"Our nurses have found ways to connect with patients who need that extra level of comfort and support.” Nicole Stipo, MSN, APRN-CNP, Clinical Leader

Cancer Update | September 2020

Currently 115 research studies are ongoing. These include NCORP treatment and care delivery trials, pharmacy/ industry sponsored trials and translational research studies.

Patients stay strong on clinical trials despite COVID-19 concerns COVID-19 can’t stop clinical trials from bringing the latest cancer therapies to patients at the Helen F. Graham Cancer Center & Research Institute. New patient enrollment and study participation have stayed strong, as national accrual levels slowed dramatically. “Across the country, many health care facilities have temporarily suspended or restricted research activities,” said Cancer Research Director Kandie Dempsey, DBA, MS, RN, OCN. “At our cancer center, rather than stopping clinical research, we chose to

meet the challenge of providing continuity of care to those already enrolled and to ensure clinical trial participation continued to be an option for our patients.” ChristianaCare’s Cancer Research Program has consistently ranked as one of the nation’s top enrollers in cancer clinical trials. The Graham Cancer Center is part of a select group of centers funded by the National Cancer Institute (NCI) to participate in the National Cancer Institute Community Oncology Research Program (NCORP).

“We chose to meet the challenge of providing continuity of care to those already enrolled and to ensure clinical trial participation continued to be an option for our patients.” Kandie Dempsey, DBA, MS, RN, OCN, Cancer Research Director

“Cancer doesn’t back down in the face of COVID-19 and neither do we,” said Nicholas Petrelli, M.D., Bank of America endowed medical director at the Graham Cancer Center. “Our clinicians and research nurses are committed to providing comprehensive cancer care in a protected environment that includes access to potentially life-saving investigational medicines. What we learn from helping trialeligible patients today leads to improving

future cancer care in our communities.” At the Cancer Center, success is a team effort. Every new patient is screened for

“We have all been challenged to think creatively about communicating with and caring for our patients in new ways." Gregory Masters, M.D., Principal Investigator, NCORP Grant

potential clinical trial participation. Cancer surgeons, radiation oncologists and medical/hematologic oncologists all work together to accomplish this and participate on multidisciplinary disease site teams that bring research nurses into direct contact with patients on their first visit. (CONTINUED ON NEXT PAGE)

TMIST trial resumes enrollment Routine mammograms are being rescheduled now on a limited basis, so the Tomosynthesis Mammographic Imaging Screening (TMIST) trial can now slowly reopen to enrollment. TMIST is a randomized breast screening trial to learn about best ways to find breast cancer early in women with no symptoms. The trial compares standard digital mammography (2-D) with a newer technology called tomosynthesis mammography (3-D). For more information about participating in TMIST, call the Cancer Research Department at 302-623-4450.

Helen F. Graham Cancer Center & Research Institute

Cancer Update | September 2020

New safety protocols put patients and care teams at the center of our COVID-19 response

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This winning combination has propelled patient enrollment over the last 15 years to nearly 30%. That is well above a 3% to 5% national average. “Since the virus outbreak, we have all been challenged to think creatively about communicating with and caring for our patients in new ways,” said lung cancer specialist Gregory Masters, M.D., who is principal investigator on the NCORP grant. “For example,” he said, “with fewer patients coming into the office we can take more time to explain to them the value of clinical trials and how their participation is good for their particular situation.” Virtual office visits afford a similar opportunity. “Telemedicine and virtual visits give us the chance to fully explain the value of clinical trial participation in digestible segments without overwhelming the patient,” he said. “ We just need to keep connecting so our patients fully understand their options.”

Helen F. Graham Cancer Center & Research Institute

Most patients receive their investigational medicines as outpatients, and some have expressed concern about coming in for treatments or testing during the pandemic. However, with new safety measures in place to protect against COVID-19, many continue to see clinical trial enrollment as a means to potentially improve their own health as well as to help others in the future. “As long as we communicate to patients what to expect in advance, and stay in touch to answer questions or concerns, we have found that most individuals are comfortable to enroll and stay committed to the research study participation requirements,” said Dempsey.

t the Helen F. Graham Cancer Center & Research Institute, the well-being of both patients and care teams is a top priority. In response to the coronavirus, some things have changed to ensure infection protection for everyone who enters the Graham Cancer Center, starting at the front door. The friendly face of a greeter is often the first that patients and visitors see as they step from their cars and through the entryway. Greeters now wear the latest personal protective equipment

or PPE. Behind facemasks, they still smile “hello” with their eyes. Nurses and medical assistants are outside too, taking temperatures and screening for symptoms, while drawing aside those who may be at risk or ill, to minimize the chance of others getting sick. For months, entry into the building has been restricted to the East and West main doors. Everyone, including staff, is screened. The visitor policy now limits the number of people inside essentially to care team members and patients who (CONTINUED ON NEXT PAGE)

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“One of the hardest things we had to do was to ask our patients not to bring a loved one or support person with them."

“The entire cancer center team has worked together to get through these challenges in ways that have made us a stronger, smarter group,”

Tammy Brown, MSN, RN, OCN, Cancer Care Management Director

Cindy Waddington, MSN, RN, AOCN, Cancer Program Clinical Director

have an appointment. Visit ChristianaCare. org/Coronavirus to check the latest visitor guidelines. This is important because cancer patients with weakened immune systems or taking immunosuppressive drugs are at higher risk for infection and the complications associated with a virus like COVID-19. “One of the hardest things we had to do was to ask our patients not to bring a loved one or support person with them,” said Cancer Care Management Director Tammy Brown, MSN, RN, OCN, who supervises the screeners. “Infection is one of the greatest risks for our cancer patients, so we have to be strategic about who comes into the building in an effort to protect everyone.” The team will make accommodations for patients who require a caregiver’s assistance at their appointment. The Oncology Express Unit at the Graham Cancer Center is also available to isolate at-risk patients for treatment in a private room when necessary. Inside looks different too. Waiting room chairs are spaced further apart, hand sanitizer is abundant and posted reminders help keep

Helen F. Graham Cancer Center & Research Institute

everyone social distancing by at least six feet. Patients and care team alike wear a mask or facial covering. Extra cleaning, particularly in hightouch areas, is part of the new protocol. Conversations with providers may happen differently. Telephone or telemedicine visits are more frequent for patients whose nonessential clinic visits can be safely delayed. For some patients, providers may suggest a change in treatment strategy to reduce the risk of infection such as chemotherapy before surgery, an oral drug in place of an infusion, or a shorter course of radiation.

Daily huddles help keep everyone in the loop “The entire cancer center team has worked together to get through these challenges in ways that have made us a stronger, smarter group,” said Cancer Program Clinical Director Cindy Waddington, MSN, RN, AOCN. “We continue to evaluate the decisions made in crisis mode, as we move forward better prepared to meet our next new normal.”

And some things haven’t changed. Those who need timely treatment get it. The Graham Cancer Center’s multidisciplinary teams of specialists continue to consult with patients and develop new treatment plans for their particular type of cancer. Nonelective surgeries go forward and

radiation and chemotherapy happen. Clinical trials and translational research projects continue to provide life-saving medicines to patients who need them now as our team looks for new and better ways to improve cancer care for everyone.

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