publication date: May. 15, 2020

Nancy E. Davidson, MD

President and executive director, Seattle Cancer Care Alliance

Senior vice president, director and member, Clinical Research Division, Fred Hutchinson Cancer Research Center

Raisbeck Endowed Chair for Collaborative Research, Fred Hutch

Professor and head of medical oncology, University of Washington

This story is part of The Cancer Letters ongoing coverage of COVID-19s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is availablehere.

Nancy Davidson is now in the eleventh week of managing the COVID-19 pandemicthe longest stretch experienced by any health executive in the U.S.

And now, like her peers throughout the country, Davidson, president and executive director of the Seattle Cancer Care Alliance, is in the midst of ramping up plans for a comeback of cancer services.

The Cancer Letter asked Davidson to discuss these plans and share her thoughts on the way cancer care will evolve both at SCCA and nationwide.

This conversation is part of an informal series of stories, interviews, and commentaries that track cancer institutions as they seek to reopen, reorganize, and reinvent in the wake of the COVID-19 pandemic:

Health systems and academic cancer centers are cutting expenses to make up for operational shortfalls resulting from the pandemiclaying off employees, furloughing staff, and cutting salaries and benefits (The Cancer Letter, May 8, 2020).

Community oncology practices are experiencing a significant decrease in patient volume, as weekly visits dropped by nearly 40%, while cancellations and no-shows have nearly doubled (The Cancer Letter, May 1, 2020).

Washington was the first state to record what at the time was believed to be the first COVID-19 caseon Jan. 15, in a traveler from Wuhan, China.

Washington was also the first to register what appeared to be the first COVID-19 death, and SCCA as well as Fred Hutchinson Cancer Center, a component of the alliance, were the first major cancer institutions to take decisive action and shut down non-essential operations (The Cancer Letter, March 13, 2020).

At this writing, the state of Washington has 18,964 confirmed cases and 991 COVID-related deaths. The disease peaked weeks ago, and the spread has slowed. On May 15, for example, 101 new cases and 5 deaths were reported in the state. Washington ranks 18th in the number of cases.

Now, SCCA is among the first to make plans to reopen its operations.

We are bringing our stem cell transplant and our CAR T programs back online in a very thoughtful way, and theres a lot of pent-up demand for that. We had over a hundred transplant patients whove been waiting in the queue, for example. And so, were beginning to recall them and bring them in, Davidson said to The Cancer Letter.

We looked at things like imaging, close to a thousand mammograms that didnt take place because screening mammograms were paused during this time of maximum separation. And so, were also beginning to think about how we can thoughtfully recall those patients. Some patients who had more elective therapies also put it off for a while.

And so, we have a pretty good idea of what the numbers are. I mean, youre right. We are actively reaching out to patients and letting them know that the system was always safe. But were now at a position where we think that they can safely come for their in-person care.

And I think thatll be an important thing going forward, especially in cancer. You and I know that cancer didnt take a pause during the COVID pandemic, and it isnt taking a pause in the near future. We really need to be in a position where we can try to optimize our care going forward. We do know that some of our patients are worried. Theyre concerned about the possibility that they would somehow increase their exposure by coming in to their visits. And so, we have very, very robust testing in place in Washington. Thats also helped us.

Davidson spoke with Paul Goldberg, editor and publisher of The Cancer Letter.

Paul Goldberg:

You have more experience with more phases of COVID-19 than anyone else in the U.S. So, going back to the beginning, to what feels like a decade ago, you moved very, very fast and set up prioritization, and closed things down. What was it like to be on the inside of those decisions?

Nancy Davidson:

Paul, youre right that were in the 10th week of our pandemic response at the Seattle Cancer Care Alliance. As you point out, we are the first of the United States NCI-designated comprehensive cancer centers to experience this in a meaningful way. And at the time, I think that we knew that we were entering into uncharted territory, but territory that we were well equipped to deal with.

As you point out, were in a state that has had a very robust response.

We work at an institution that has a lot of people who are already involved in research in viruses. Fred Hutch houses one of the big coordinating centers for the HIV vaccine efforts, so that we felt that we were in a good position to do this, but we were kind of learning on the job.

Oncologists, though, are very good at dynamic situations, and tackling risk; right? Thats what we do for a living.

PG:

Well, you have also seen more impact on your institution and research, both clinical and basic. How would you summarize this impact?

ND:

We have seen much more impact than all of us would like on our cancer research.

Obviously, our COVID research is flourishing right now, but on the cancer side, we made the decision institutionally, across Fred Hutch and Seattle Cancer Care Alliance, to really slow down our basic laboratory research in accordance with the state guidelines and with our own modeling about what we should do to try to flatten the curve.

And we also made the decision to really limit access to some of our clinical trials, particularly the phase I clinical trials, where we felt that the real goal of a phase I trial is toxicity rather than improving patient wellbeing. And we also closed some of our phase III clinical trials, because we felt that a standard treatment option was available for those patients.

But Paul, weve continued our phase II clinical trials all during this time, for patients where we thought that clinical trial participation would be important for their wellbeing, and we certainly have continued care on trial for everybody who was already on trial. The new accrual was limited more to folks who were going on to the phase II trials.

And were now doing the reverse.

Were at a point where were able now to think about how to wind up after the wind-down. And so, right now, we are, in a very thoughtful and deliberate fashion, opening about 10% new trials and 10% of our closed trials over the next week or so.

Well look carefully at the impact of that, and then we hope to continue that ramp up in a stepwise fashion. And weve tried to prioritize those for trials that are in patients best interests, trials that really reflect some of our primary research interests as an institution, and those where we think that we can try to optimize the safety of the participants and our staff.

PG:

Do you think anything has been irrevocably lost, in terms of data?

ND:

I think that in some of our clinical trials, we werent able to collect every single piece of data that mightve been mandated by the clinical trial.

Certainly, we were able to collect all the data that would be vital for patient safety. And we may not be able to get all of those things, but I suspect that for the clinical trials that have remained in operation and those that will be restarting, that well be able to gather the information that we need to address the primary aims of the clinical trial.

PG:

Ive heard it said that with randomization, problems affect both sides of the trial. So, with randomized trials, you might actually be in okay shape.

ND:

I think so. Many of the randomized trials are very large trials; right? And one would hope that what were going to see is a short period of a pause, and then, youre right, the trial will resume in its full form, and that we will not have any compromise of the primary outcome of the trial.

PG:

What about clinical care? Has that been set back?

ND:

No, I dont think so. I do think that oncologists are pretty good at dealing with adversity, as are our patients. So, we have remained operational the entire time. Weve actually used this as an opportunity to accelerate some of the initiatives that we probably should have done before.

All of us have become very adept at telehealth now, and we are hoping that well be able to right-size how we would use that going forward. And, of course, were hoping that the reimbursement strategies nationally will make that a viable alternative for some patients where its appropriate.

We continued all of our infusion therapies, by and large. The one place where we made some pretty strategic decisions was to slow access to our cell-based therapy trials and treatments, our CAR T trials and our stem cell transplant trials.

As members of a healthcare ecosystem, we needed to be in line with the priorities of the state of Washington and the Puget Sound region at the time, to make sure that we freed up inpatient beds and critical care resources for what we thought would be the surge of COVID-19 patients.

And so, that meant that those transplant and CAR T patients were the patients who were the most likely to require those things, and we made the decision to slow their entry into our system. Were now restarting that, too, Paul. As of last week, were reentering some of the most needy patients who require those particular kinds of interventions, because we feel that we have the hospital capacity to care for them should they become ill.

PG:

Have you had to do triage on COVID? On, say, ventilators?

ND:

Thankfully, we have not. I think, again, the state of Washington has been very forward-thinking on this. In our state, early on there were a lot of workplaces that put people to work from home. The Fred Hutch and the SCCA did this early on; the governor has been very diligent in the state of Washington.

And so, I think we were in happy circumstances where, thankfully, our critical care capacity was higher than our needs. And so there was never a time that Im aware of where in the University of Washington system we had to triage the use of ventilators.

PG:

What role have disparities played in this crisis?

ND:

Well, gosh, I think thats an area where were all trying to sort it through; right?

Our region has a large homeless population. Thats certainly a major form of disparity. And so, I think that within the region, were trying to work collectively with our government facilities and with our partner organizations to make sure that our homeless population has access to the kind of care that they need across the boardthings that are related to prevention or treatment in COVID, as well as underlying social and health problems that they might have.

Ours is a state that has a large Native American population, and so, were trying to make sure that we work pretty actively with our tribes, where appropriate, to make sure that theyre getting the appropriate health care.

And you may know that also in our region the Yakima Valley, which is in the middle of the state, is the home of our larger Hispanic population. That region has been particularly hard hit, and I think that might have to do with the nature of the workforce and the kinds of jobs.

These are folks who often work in situations where its hard to distance in the workplace, and they work in vital industries, and so, this is a population thats also been especially hard hit. So, were trying very hard to make sure that we understand these individuals who are at particular risk, and we do everything we can to try to mitigate that risk within those individuals.

PG:

How soon do you think you might have some data?

ND:

I dont have a good answer for you on that one right now. I think that everybody is pedaling as fast as they can, Paul, to try to get data generally. And then, also, for specific populations.

For example, populations of patients with cancer.

AACR had a session where they tried to review what we know about cancer as a risk factor for COVID, and it looks to me like we dont have a clear understanding of that as a field, either. So, there are a lot of places where we have knowledge that we really have to gain over relatively short period of time.

PG:

What about financial impact? Have you had to have furloughs or any other forms of belt-tightening?

ND:

We think our workforce is incredibly important. Thats obviously one of our most important resources, and so, wed like very much to retain our workforce as best as we can going forward. Weve been fortunate that many people were in a situation where they could work from home.

And so, many of our workforce members who dont have to be physically in the office or who are not directly patient-facing are working from home and theyre working extremely hard.

I think it will be interesting to see how it goes over time. What the healthcare workforce looks like generally is something that were all going to need to be thinking about as we go into the months and the years aheadwhat weve learned from this, and what we can use to try to optimize the delivery of healthcare going forward generally, and also the delivery of cancer care specifically.

PG:

People talk about a rebound in demand for carepatients showing up saying, Take care of us. You should probably be starting to see it about now, I would think. Is it happening?

ND:

We are hoping that were going to see that shortly, and, actually, were trying to begin to promote that, if you will.

First, I told you about the fact that we are bringing our stem cell transplant and our CAR T programs back online in a very thoughtful way, and theres a lot of pent-up demand for that. We had over a hundred transplant patients whove been waiting in the queue, for example. And so, were beginning to recall them and bring them in.

We looked at things like imaging, close to a thousand mammograms that didnt take place because screening mammograms were paused during this time of maximum separation. And so, were also beginning to think about how we can thoughtfully recall those patients. Some patients who had more elective therapies also put it off for a while. And so, we have a pretty good idea of what the numbers are. I mean, youre right. We are actively reaching out to patients and letting them know that the system was always safe. But were now at a position where we think that they can safely come for their in-person care.

And I think thatll be an important thing going forward, especially in cancer. You and I know that cancer didnt take a pause during the COVID pandemic, and it isnt taking a pause in the near future. We really need to be in a position where we can try to optimize our care going forward. We do know that some of our patients are worried. Theyre concerned about the possibility that they would somehow increase their exposure by coming in to their visits. And so, we have very, very robust testing in place in Washington. Thats also helped us.

Go here to see the original:
Nancy Davidson describes plans for reopening the Seattle Cancer Care Alliance as COVID-19 wave recedes - The Cancer Letter