How I Cope with the Tsunami of Cancer and COVID-19 Info
Oncologists worldwide face the challenge of staying on top of the latest treatments, research findings, and other information that could help them treat their patients more effectively. Now, they must do so in the context of COVID-19. Here, our Curious Dr. George asks Kevin Knopf, MD, MPH, Division Chief of Hematology/Oncology at Highland Hospital/Alameda Health Systems in Oakland, California, how he keeps up.
Curious Dr. George: Even without COVID-19, the field of clinical oncology is changing so rapidly. How do you, as a practicing oncologist, keep up with new information about cancer and COVID-19? On a day-to-day basis, do you mostly rely on the best medical journals, emails from medical associations, government agencies, press releases, actual or virtual medical meetings, hospital conferences, mainstream media, social media, or what?
Kevin Knopf, MD, MPH: There are three key journals I read regularly: two weeklies—The New England Journal of Medicine and Blood (the journal of the American Society of Hematology)—and the thrice-monthly Journal of Clinical Oncology (American Society of Clinical Oncology or ASCO). They all have excellent updated guidelines on cancer care, including during COVID-19. Medscape Hematology – Oncology is a fourth online publication that I read daily. There are several other fine journals in oncology* that I read, but their web presentations are not quite as robust. Together, these four periodicals have done an outstanding job of curating scientific and clinical information about COVID-19 and publishing it quickly online prior to print publication.
As Division Chief of Hematology/Oncology, I must also set guidelines and policy that affect our entire hospital and health care system. We were quick to adapt our chemotherapy infusion suite for COVID-19 safety based in part on shared information. Triage of outpatients has been an ongoing challenge and an iterative process. ASCO guidelines and rapid publication of information have been key in my ability to care for our patients.
I’ve also discovered another fascinating development on keeping up with cancer care during COVID-19. I registered on the Twitter-based community #MEDTWITTER in 2013 to follow what was happening in academic oncology, see new clinical developments, and learn and interact with colleagues. On Twitter, we debate the latest findings in hematology/oncology and share articles with each other. For the record, I think one of the first physicians to predict the magnitude of the COVID-19 tragedy is Christos Argyropoulos, MD, (@ChristosArgyrop), a brilliant nephrologist and researcher in New Mexico who pondered the epidemiology of COVID-19 well before the first case in the United States. My friend Dan Goldstein, MD (@drdgoldstein), retweeted a video featuring Italian pulmonologist’s experience treating COVID-19 in Italy on March 10—the day things really sank in for me. A video on Twitter can be worth more than 1,000 words. Now, I follow the Twitter accounts of several epidemiologists and molecular biologists engaged in COVID-19 research.
While rapid information has been brought to bear on COVID-19 during this time of crisis, many shoddy and methodologically flawed scientific “studies” have been rushed to publication. For instance, recent discussion has focused on the retraction of some highly flawed publications on hydroxychloroquine. Journalists Jeanne Lenzer and Shannon Brownlee have written eloquently about these problems.
An illustrative and highly pertinent ongoing issue is whether we should change our clinical approach to treating COVID-19 patients who have acute blood clotting disorders—strokes, pulmonary embolism, and the like—who often die, even of disseminated intravascular coagulation. This question touches on not just the biology but the nature of clinical research; it is now known that patients in the intensive care unit with COVID-19 have a high incidence of thrombotic (clotting) complications, but whether and how to intervene is being debated.
In clinical medicine, when possible, we conduct prospective randomized controlled trials to minimize confounding and bias in order to get closer to the truth of whether an intervention helps or harms a patient. The principle is that while retrospective trials are hypothesis generating, prospective trials help to prove or disprove a hypothesis. In this context, several institutions have been interpreting the retrospective data to recommend more aggressive anticoagulation for patients with COVID-19. I’ve had to sit tight and believe what I believed before—that this doesn’t make sense. On Twitter this has been debated extensively, even with a picture of a patient who died from a bleed into the brain caused by excessive anticoagulation (arguing against this practice). For my institution, I have not recommended changing our approach of not anticoagulating COVID-19 patients, but I am monitoring the evidence daily.
So much is changing in our communication about cancer care as a result of COVID-19. I gave my first online lecture to an international conference on March 9. And, our usual ASCO meeting of 60,000 people in Chicago was instead held completely online while (coincidentally) peaceful protests and violence in the streets erupted over George Floyd’s death. The convention center for this meeting had been converted into a COVID-19 hospital in anticipation of a tsunami of cases in Chicago. Interestingly, the academic oncologists on Twitter are mostly commenting about how nice it is to not have to travel for a meeting; the only part we seem to miss are the social interactions with each other.
The internet has dramatically improved how we practice medicine and share knowledge in cancer care. Now, COVID-19 is another jolt to the system that will change how medical information is generated and disseminated. As a physician practicing at a county “safety net” hospital, I predict dramatic changes in cancer care as more than 27 million Americans have already lost their health insurance due to the pandemic. This erosion of coverage may herald a sea change towards more value-based cancer care as the finances of cancer care in 2020 and beyond are challenged.
*Additional important journals for hematologists/oncologists include The BMJ, The Lancet, The Lancet Oncology, JAMA Oncology, The Oncologist, Clinical Advances in Hematology & Oncology.
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