Dr. Kutikov presents Cancer and COVID-19: A War on Two Fronts.
well, thank you very much. Thank you everybody for joining us. Thank you for the sponsors. Um What a crazy world we live in. I'll kick it off with a joke. Why can't ants get Covid? They have antibodies of course. Um, so I thought I'd say just a few words about cancer and Covid and the reality that we find ourselves in. Um this is Covid as of two days ago. I mean, unbelievable. You know, 51.5 million deaths subscribed to Covid in the world With nearly 300,000 deaths in the United States. And if you know humans, humans have around 20 to 25,000 genes, I don't know if you know, but Covid only has 29 jeans. Okay, so 29 genes coding for actually 28 proteins. One of the one of the jeans is a non coding gene, 28 proteins that really changed the world. And when you look at the biology of SARS COv two, which is the virus that causes causes covid. And in the biology of cancer there's there's some there's some intersections that are actually interesting. So uh as a lot of you know starts Kobe to binds to the ace two receptor which is really appears to be up regulated with age and appears to be up regulating smokers and in those with lung cancer. So you know as well talk our lung cancer patients are actually some of the most susceptible to severe covid. Um what's really interesting especially during a g you talk is that this temptress gene which as you know, about 50% of prostate cancers have a temporary ERG gene fusion mutation. Uh This tempers gene basically cleaves the ace two and the SARS-COV-2 spike protein bond and allows Covid allows SARS-COV-2 to enter the cell. And it looks like uh this you know, this temptress. Uh This temperance is a serum protein protein is actually its expression is very much androgen dependent and it looks like it's modulated by A. T. T. Apparently according according to sort of the last time I looked there hasn't been a reported case of a severe covid and somebody on A. D. T. Because people think their tempers gene is so down regulated. The big question is whether sort of the disruption of natural barriers and cancer induced immune suppression and the cytokine storm, is it worse in patients who are immuno suppressed patients who have cancer patients who are undergoing uh immunotherapy or chemotherapy. And that's still a big question where we know that COVID-19 and cancer do do do dovetail is in this in these three symbolic events um cancer predisposes you to uh pro coagulant state. And so does Kobe to and potentially a very lethal combination when those to meet and one individual. Um so to drill down into kind of the key questions that we have, you know, in patients with covid and cancer is cancer patients more vulnerable to stars Kobe too well, doctor businessman Dr Russo and I sort of got invited to start this effort for us. Up to date. We've been writing a couple of, a couple of sort of up to date chapters on covid and cancer starting from the beginning. And it's been really interesting to watch this literature emerged in the beginning. The narrative was very strong that cancer patients are much more susceptible to covid. And as more robust data has emerged, it really is unclear as when, you know, when you control for age uh morbidity uh for sort of impact of recent cancer treatment when you control for all of those things. You know, the signal is not as strong that cancer patients are more susceptible to covid and are more likely to get a severe covid um, cytokine storm, what is clear is that there is, you know, the most consistent findings that patients with lung cancer and patients with human logic malignancies are, you know, do indeed look to be much more susceptible to covid and severe covid uh disease. Um, so, you know, the biggest challenges and you know, we try to crystallize this out in the in these up to date articles is really balancing this uh these competing risks of serious complications of covid versus delay and progression of cancer. And you know, also there is likely at least, although it's hard to prove there is likely a higher legality to covid 19 and immune suppressed host. So again, how do you balance delay in treatment versus delivering care during covid waves and taking those risks? You know, I'll talk to to that a little bit in the second. So the biggest sort of uh you know issue at least in surgery is is this there is a 24% 30 day mortality in patients who get covid around the time of their surgery. And these are data for mostly Italy spain UK in the US. And these are data from from surgeries that were done Before March 31. And there's a highly fatality rate. There's similar data from china and you know, this gave us all pause, especially in the beginning of the pandemic on whether to proceed, especially with elective surgery uh during uh during uh the especially the lockdowns and when the numbers were high, we now think that a lot of this risk can be really mitigated by testing patients for SARS COV two prior surgery. But still there are some risks that patients walk into when they undergo surgery during these times. Um chemotherapy and immunotherapy. It's less clear cut. Um Asco guidelines really advise a case by case based decision and similar similar decisions really need to be made when administering um radiation therapy and so this is you know, just just kind of to show. On March 27th we published uh this paper and annals and you know, this was really done in the absence of any data. We basically said what can we push off for three months? Uh and what can we push off? And kind of this this chart I got adopted adopted by lots of different publications. I think this is approaching you know, 100 references out there um to create charts like this where you know which surgeries go and which surgeries don't go. This was our our list of surgeries that were hard stop versus you know, yellow and green from March to april before we really rolled out testing at Fox Chase and what we really stopped, we stopped prostate cancer surgery for about six weeks and we stopped some really set a reductive surgery for about six weeks until we were we felt it was safe to resume. And here is above the fold health section of of the Enquirer with one of my patients whose side of reductive surgery was pushed on pause and you know, just show can really describes how much anxiety, anxiety these patients went through just by delaying an operation that was already on the books. Um You know, and cancer treatment delays. They're real and you know, this is um these are recent data in bladder cancer patients. Uh these meta analysis that show that the delays, especially for some of these aggressive cancers really translate into a worse survival. And how do you sort of quantitative these risks and how do you balance the two? This is a good tool. This is a link it's called on covid from University of Michigan's. It basically takes data county specific data for your area and looks at N. C. B. And C. Are data and kind and sort of integrates it too. It gives you you know a estimation of Risk of postponing surgery vs uh coming up with a severe COVID-19 episode. So interesting data to have as a jumping off point for some clinical decision making. Um A little bit about testing whom to test obviously patients with symptoms or history of exposure who get tested, Asko. And the A. C. S. Guidelines do not support uh testing prior to initiation, immunosuppressive therapies while infectious disease society of America does. So there's still split opinions out there. Uh testing prior to procedures is not strongly recommended. But most hospitals are doing it. We're doing things that it gives everybody a level of comfort. The patient is not coming into a big surgery with Covid with the stars Kobe to infection. And in most hospitals in philadelphia as far as I know in patients all in patients are being tested even if they were admitted. You know outside of sort of a surgical pathway. Um How to minimize uh the compromise of physical distancing. We talked about this uh in sort of a session right before this telemedicine has really changed the landscape of outpatient care. Um And really it's been this you know this parody uh between telemedicine and clinic based care that CMS has uh sort of overnight imposed where you know there's equivalent reimbursement for and now patient visit versus a telemedicine visit. Um interestingly out of state license requirements have been largely waved. I've been seeing patients from really all over the country, whereas before this was not possible. Um So before I end, this is from today, this is this is Pfizer biontech filing to the FDA. Okay, this is days from administration of the first Pfizer vaccine. Okay, the red is um the red and I don't think there's any political overtones in this graph, although one would wonder the red is the uh placebo and the blue Is the vaccine. And as you can see a day 10 of the vaccine, your chances of getting COVID are basically flat. It looks like even after the first dose. Uh this uh this blue line sort of uh is a big winner here. So um whom to vaccinate. We're all struggling with this now underlying medical you know conditions uh are gonna take priority. Um And it looks like vaccination recommendations against influenza. Maybe a guide. So recommended for individuals under active treatment for cancer or for up to two years following some treats and treatments of human logic cancers. Uh Long term survival is in no recent immunosuppression of treatments are not considered high risk in vaccinations, guidance from the A. C. S. So people think that these recommendations that are standing out for influenza are probably going to guide the covid 19 uh a triaging of patients for the vaccine. And uh in conclusion cancer required calculation of risk. Just like everything that we do. Um there will be likely very long lasting impact on cancer care from COVID-19. And there's this new vaccines really hard. A tremendous hope. This is Elvis getting his polio vaccine. I'm curious to see who is going to be on television getting their code vaccine soon. So without further ado dr Zimmerman