COVID-19 and Cancer: Karmanos Cancer Institute Adapts to New Challenges | Justin Klamerus, M.D., MMM

Dr. Justin Klamerus, president of Karmanos Cancer Hospital & Network, discusses how the Institute is adapting to new challenges during the COVID-19 health crisis.

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Caitlin Whyte: Coronavirus has us all worrying about our health and the way we interact with others, but for those who are immunocompromised, that worry may be heightened. Today we're talking about cancer care during the COVID-19 pandemic with Dr. Justin Klamerus of the Karmanos Cancer Institute. I'm your host, Caitlin Whyte. Dr. Klamerus, what is different about a cancer hospital's response and the response of a general hospital?

Dr. Klamerus: I would say first and foremost in our priority is that cancer patients can have very significant weakened immune systems. We think of cancer not only leading to weakening of the immune system, certain types of cancers like blood cancer, but the very treatment that we give patients that can be lifesaving weakens their immune system, reduces their white blood cell counts and puts them at risk for usual infections that we see. So certainly the concern in the early data with the COVID pandemic is that cancer patients are at increased risk and and unfortunately that their outcome may be worse if they are infected. That's the biggest factor for us.

Host: So we're hearing about these Coronavirus hotspots and Detroit has been among them, but Karmanos Clinic locations are throughout Michigan. So how are you seeing different situations arise throughout the network?

Dr. Klamerus: We indeed are seeing just as, as the State maps of incidents of infection show, various centers around the State having different severity levels of infection rates in their community, and sadly deaths at the extreme end. What we are noticing certainly in Detroit, is that the City, Wayne County and Oakland County and Macomb County are seeing very, very high levels. In fact, upwards of two thirds of the cases in the State are in those areas, the most densely populated areas of the State as well. We are seeing cancer patients who are becoming infected with COVID at all of our locations. Our highest rate has been in Detroit, but that's simply a matter of the number of patients that we're seeing and the volume there. One thing that, and I know that we are still potentially in the early days of this pandemic and all of us in healthcare are preparing, for a wider, longer period of duration of this infection in our communities.

We aren't seeing as severe of a surge as was anticipated among cancer patients in our region. And we have some theories on that. I know when patients are diagnosed with cancer, we give very good instructions about how to stay healthy during times of risk. For instance, every year with the flu season, we limit visitation to our facilities. We talk to patients about the need for, it was never a term that we had social distancing before now, but certainly encouraged whether it were grandparents to avoid grandchildren when they were receiving chemotherapy or certainly grandchildren that were sick. And so we believe in the early parts of this. And as I talk with colleagues from around the country, they're seeing the same thing that perhaps our cancer patients were more cautious, but they were practicing some of the good social distancing, hand washing hygiene that the general community was probably too slow to embrace.

Host: We're hearing about telemedicine being such an important service now that we're keeping people away from hospitals as much as possible. How are you utilizing this service to serve your patients?

Dr. Klamerus: Sure. Well we are using telemedicine widely throughout our statewide network. Most of our physicians have some part of their usual patient care being done, through telemedicine and that takes many forms. Our health system, McLaren's Healthcare has an established telemedicine platform called McLaren Now. Some of our providers are utilizing that. However, the demand for that service in the statewide catchment that McLaren has been so severe that we are using other medically approved telemedicine platforms. It was also put out in federal guidance that physicians should feel comfortable using FaceTime, telephonic visits, etcetera. So any way we can connect with patients, we're doing that. We've also brought our IT professionals together to work with our patient navigators to reach out to patients, to really be IT support to our patients, into our physicians who maybe didn't use telemedicine before but now need to rapidly develop that skill to stay connected.

We're supporting providers in any way that we can. One distinction in cancer medicine in the State of Michigan that Governor has, you know, put out very clear direction about what's essential and non essential services. Clearly cancer therapy is an essential service that we can't interrupt cancer treatment for this virus. Yet we have to be careful and cautious. What we've done is we continue to see at our facilities across the State, those patients who are on active treatment, whether that be surgery, chemotherapy or radiation, and those who have symptoms that are suggestive of a new cancer diagnosis or those who may have progression of their disease. If they were on surveillance and being monitored, we are still fully engaged in that active care patients.

Host: So what message would you share with those who might be fearful about seeing a doctor at this time, even if they may have symptoms that could indicate a cancer diagnosis?

Dr. Klamerus:I think that the fear is a natural part of our society right now. We in an unprecedented time and all of us are living through things that we've never seen before. I'll tell you what we are doing to minimize that risk, at every single one of our hospitals, ambulatory centers, cancer clinics, infusion centers, radiation centers, we have screening mechanisms in place. Firstly, patients are screened by, um, navigators the night before. They come to their appointments to ask if they have concerning symptoms, if they've had exposure to anyone with COVID or if they have sought care for any symptoms, suspicious for COVID. And if so, we're following a different algorithm for those patients. Then we also have screening that happens at our doors. If anyone has symptoms, if anyone answers the symptom questions or has had exposure, we are immediately placing masks on those patients and putting them in isolation so that they're not exposed to the routine population.

And so we're following the very ordered and structured process for how we keep not only our patients safe, but our staff safe as well. And what I would say is we can't underestimate the potential risk of not seeking medical care when you need it, even though this virus is very concerning to all of us. And it's a crisis of unparalleled magnitude. And in recent times, what is very true is that if we look on our individual risk, that risk is relatively low, especially when we practice the social distancing, when we're attuned to the symptoms that we have, when we stay home when we're sick, if we follow those processes, there's no reason to think that people can't come and get active therapy for conditions and treatments they need. We're seeing that at cancer programs across the country, including at some of the first cancer centers that have experienced outbreaks of this virus. For instance, at the Fred Hutchinson Cancer Center in Seattle, active discussions with their team about what they've experienced and we're all learning together across the country as we face this together.

Host: But what about fear amongst referring providers? How can we reassure doctors about sending their patients over to Karmanos?

Dr. Klamerus: I think two points to consider with referring providers, sending patients to us first that we continue to be open to see new patients and we're doing that throughout our statewide network. But one thing that we are also seeing, especially at our Detroit facility is many of our general acute care hospitals in the surrounding metropolitan area have been so overwhelmed by the COVID virus patients and those infected or suspected, that they are deferring and in fact referring a number of critical patients to us. Patients with acute leukemia, patients who need cancer surgery. We're seeing those patients because their teams are so overloaded with the cases that they currently have for COVID. So this is a part of our daily routine and we're seeing more and more of it as we go through this crisis. For referring providers though I would say the same thing that we're being very careful about their patients to the screening, avoiding bringing patients to the facility who are having active symptoms of infection. And we also have fairly strict guidelines about, you know, exposure, time from exposure, time from symptoms before we bring people to our facilities. And certainly before we start any new therapies that would compromise individual's immune systems.

Host: So Doctor, you mentioned, you know, essential services versus nonessential services. Are there patients who should delay their cancer treatment during this time?

Dr. Klamerus: We certainly are continuing to assess that on a weekly basis. When we first started when we first saw cases in Michigan, we were not as conservative. We were telling patients to continue to come in who are on treatment. And as we saw that Michigan was turning into a hot zone for this virus, we certainly adjusted our guidance and expectations there. I'll give you one example. We do a large number of allogeneic bone marrow transplants or STEM cell transplants at our facility. And I think most of our physicians would agree that they are probably at the highest risk because we take their bone marrow, where all of our protective white blood cells and the cells that fight infection have immune memory live. We take those cells and destroy them and eliminate them and then then give a transplant of someone else's bone marrow. So there are very, very high risk.

We stopped all non-essential transplants in this period until we knew what was going on. Only patients whose lives would be affected if we didn't start the transplant. And so we've ratcheted down the number of transplants that we've done. I've had conversations with breast surgical oncologists, individuals who manage breast cancer. We're certainly limiting and delaying by a few weeks. Some of those surgeries, knowing that a few weeks really does not matter in terms of the progression of certain types of cancers. But as we all know, cancer is not a single diagnosis. Cancer is, you know, four or 500 different diagnoses. So our physicians really in each multidisciplinary team are crafting their own guidelines for what they believe for each circumstance for patient is an appropriate delay and in some we can't delay at all.

So we're treating each patient as we always do, doing an individual assessment of risk, doing individual assessments of do we have the resources available to treat that patient. A lot of discussion has occurred in the public and rightfully so, about shortages of medical supplies. We know that individuals who have surgery require some of the same isolation, equipment, gowns, gloves, etcetera, face masks, that we need at the front lines for personal protective equipment for our staff. So we want to be mindful that we have the right supplies and that no one on the front lines of fighting the virus is compromised in terms of their equipment. But those are just assessments that we're doing on an ongoing basis. I will say that I believe at this time we are starting to see a decline in the demand for acute care services for COVID patients at most of our centers around the metropolitan Detroit.

Within McLaren where we're seeing a stabilization almost in many markets of the number of new cases, so we're having that question actively about how we return and get patients who need treatment even beyond cancer. For instance, if you have an aneurysm and you need surgery for that aneurysm, there may be risk and delaying further. So we have ongoing discussions with state health authorities to really convey what we're seeing on the front lines with what the best public health guidance is.

Host: If a cancer patient or cancer survivor is showing symptoms of Coronavirus, what should they do?

Dr. Klamerus: I would say that the first thing to do is to contact your physician, your provider, and let them know of symptoms. If you're having symptoms, you should be tested. We work in an individual basis and your physician can direct you where to get testing. The good news is that testing is more and more available in the State of Michigan. Our initial priority was on inpatient testing and now I think that most facilities within the state have access. Certainly all of our McLaren and Karmanos facilities do, but even another health systems have access to testing. We are seeing more and more availability of outpatient testing available. It helps us to have the test result one, to know who those patients are to help those patients be isolated as well from anyone that they might encounter that that they may pose a risk of infection to those individuals. That's really important and then of course staying connected to your provider with the symptoms you're having. Recognizing some of the early warning signs of more serious infections that require patients to come into the hospital, we want to know that and our only way to know that is to be tested and to be monitored

Host: With things changing so rapidly. Dr. Klamerus, how are you and team adapting?

Dr. Klamerus: I would say that it's a time like nothing else we've experienced in healthcare. I'm also incredibly proud that everywhere I look you see people responding with enormous courage. We have members of our team who have not had a day off in five weeks that are working tirelessly to make sure we have the best information available to all of our providers and patients. It's a very trying time, no doubt about it. But I see around our facilities people coming together and supporting one another in ways that we haven't seen as a nation perhaps since 9/11. So as much as this is a terrible, terrible tragedy impacting everyone in some way, we're also seeing the best of ourselves, especially in those at the front lines.

Host: Looking into the future, what long-term effects do you think this pandemic will have on Karmanos cancer Institute and oncology patients overall?

Dr. Klamerus: You know, I think, with oncology we will perhaps, not have as great of an impact as other parts of the healthcare system because cancer medicine is such an essential service that can't wait. We've had to figure out how to provide services throughout this pandemic and for the plateau or the tail of this infection. We're planning for that and we'll need to, what I worry about most deeply is the impact to the broader health system in terms of the costs that our health systems are taking on the lost revenues that they've had and experienced. And will continue to see. The employees who've been impacted by this. I think there is not a health system in Michigan that hasn't had to furlough non-essential staff. So there's times of great economic uncertainty related to this and, and in cancer, perhaps the greatest issue may be that a lot of our research has been put on hold as we prioritize and rightfully and meaningfully so, focus on treating acute issues and dealing with the infection pandemic in front of us, but we're certainly losing time and lots of projects that were ongoing related to, to research. But we will rally to this as well because we have a lot of work to do. Our patients need us and our teams I know are just really eager to get back to work and get back to doing the things they do every day.

Host: Absolutely. And wrapping up here, are there any resources that you would recommend to your Karmanos patients during this time?

Dr. Klamerus: Well certainly. We have resources at on our website. One that is always a, that I always recommend to our patients is, G O V. That is a great website that has resources. There's a special COVID-19 section for cancer patients of that website. And the American Cancer Society also has great resources available to patients if they have questions. It's certainly a time, as I mentioned, of fear and anxiety for all, especially if you carry a diagnosis that makes you at risk for infections. But I hope our cancer patients know that we're doing everything we can to keep them safe and to keep treatment moving even through this difficult time.

: Well, thank you so much for giving us a few minutes of your time, Doctor, during what I imagine has been a very busy few weeks for you. That was Dr. Justin Klamarus of the Karmanos Cancer Institute. You can find out more about the Institute at that's K A R M A N O I'm Caitlin Whyte. Stay home and stay safe.