What the US Can Learn From Italy's Coronavirus Outbreak

What the US Can Learn From Italy's Coronavirus Outbreak.

MARCH 24, 2020 -- Marina Garassino, MD, is chief of the Medical Thoracic Oncology Unit at the Istituto Nazionale dei Tumori in Milan, Italy. The day after this interview was recorded, Italy announced that deaths from the COVID-19 virus had reached 3405, outstripping the toll in China, where the virus first hit.

In this discussion with Jack West, MD, she talks about how her team of oncologists has responded to the COVID-19 pandemic and what lessons she can pass on to US and global oncologists for the care of their cancer patients during the outbreak.

This interview has been edited for length and clarity.

You are in the epicenter of the COVID-19 pandemic right now. Can you give us a sense of what it is like currently and what it has been like over the past couple of weeks, from the inside?

We are surviving, but it's very hard. As an oncologist, I can only speak generally about COVID-19 treatments because it's not my field. We send people who are COVID-19–positive to be treated in specific centers; the intensive care is in another hospital.

How has it been working in a system as taxed as the medical system has been in Italy, in terms of how you and your cancer patients are coping?

We were not prepared because we thought that China was very far away, and Italy was a small country in a different environment and therefore it wasn't possible that we would be attacked by the virus.

The start was very simple: There was a case of a very young man in a small hospital in Emilia-Romagna, which is a small region in Italy. After watching a difficult resolution in this man, the anesthesiologist decided to do a COVID-19 test. When the test came back positive, it started the story in Italy. But we think that it was just by chance that Italy was first, and not another country, because we started to test earlier.

What we see is that you can have multiple different types of COVID-19. The majority of cases are asymptomatic. This is very important because you can't recognize them, but they are there and they can spread the virus everywhere—this is the most relevant point of the story.

Then there are patients with mild flu-like symptoms—a small fever, cough, maybe rhinorrhea, conjunctivitis.

And then you have another category of about 15% of the cases that need intensive care. If you are not prepared to have 15% of cases in intensive care, you have big problems. Sometimes you have to face decisions about which patients must go to intensive care and which will not. The problem here is not the deaths that occur mostly in the elderly; the problem is that 15% of patients need intensive care.

Most often, intensive care is for patients who present with terrible pneumonitis. Other types of presentations include diarrhea, high fevers, conjunctivitis; some cases present with ageusia, dysgeusia, or anosmia as well. Otitis can be present. So you can have multiple symptoms.

These patients can start with mild symptoms and in a short time they need intensive care. So my first suggestion is to be prepared to have enough beds for intensive care. In Italy, we have intensive care everywhere but we need more beds because there are not enough.

With so many ICU beds and ventilators occupied by patients with COVID-19, that must mean that even people with other medical problems that are potentially treatable and reversible suddenly can't get their necessary treatments.

Yes, and this is the most relevant point for oncology. We tried to avoid all follow-ups. We created a team for follow-ups to stay in touch with people by phone and to reassure them that every treatment will be finished—we will take care of them. We are also trying to take care of them through Web-based medicine. It is important that they don't feel like they are being abandoned.

But, for example, all CT scans of patients after surgery are delayed. Everything that we feel is unnecessary is delayed.

It is difficult to define what is unnecessary and what is not. We are delaying the second- and third-line treatments. We are trying to delay chemotherapy and immunotherapy treatments for 1 week. We don't know if we are right or wrong, but we are trying to make decisions based on every patient's situation and knowing that they do not have beds in the ICUs.

At the very least, the risk of COVID-19 infection needs to be factored into the balance of anticipated benefits and risks of treatments that may have a debatable, or only marginal, benefit, yet we still routinely provide.

Especially in older patients, the potential harm of causing immunosuppression may be greater than the anticipated benefit. It forces us to recalculate whether our treatments are definitely more likely to help than to harm patients now.

Yes. When we spoke with all the patients, I can say that they understood very well. They understand that they are more frail and that there is greater danger if they come to the hospital. They agreed to postpone everything as much as possible.

At the same time, we are treating in the neoadjuvant setting and first-line metastatic non–small cell lung cancer patients. But we are delaying everything that is less important. It really is not less important, but we are trying to prioritize what is life-threatening.

Do you feel that your colleagues who are on the frontlines managing patients at COVID-19 treatment facilities and in the ICUs are overwhelmed, or is the feeling at this point that they have maybe been through the worst and are better equipped to manage in the coming weeks?

In Italy, we have a public health system, so everything is paid for every citizen. There are a lot of philanthropic institutions that are donating money to get more ICU beds, so the situation now is not at the point of collapse. But we—the physicians—are not something that you can buy.

Sometimes you do have to make hard decisions. For example, a woman being treated by my group was in her last line of treatment and we decided to have her stay at home because she was positive. It's very sad because you may have helped a patient for years, and as they are dying it may be difficult to find a place for them. I think that it's important to be prepared for this part as well—to create a COVID-19–positive hospice and be prepared for every phase of the disease.

Is the general public in Italy now entirely onboard with social isolation, or are there still people who may not be responding as aggressively as the medical community would like?

The Italian people love hospitality so it's difficult for them to stay at home. I can tell you that my city [Milan] has been totally empty for 10 days, so I think that people are now starting to understand that this is a real danger and they are staying at home. You may see some people jogging or out with their dogs; there are a lot of messages saying that's okay, but there are also some suggestions that people should not go out at all.

What we learned from China is that the only way to contain the situation is isolation and segregation. We must also be aware that hygiene is very important. We have to stay at home as much as possible and convince the community to stay at home, because I can tell you that it's really frightening.

Is it fair to say that one of your key recommendations for other parts of the world, like the United States, that have yet to see the brunt of this and may be 1 or 2 weeks behind Italy, is to take it as seriously as possible and pursue social distancing and promote broad testing?

In Italy, there have been two suggestions for testing. We started by testing only symptomatic people because we had to take care of them; but now we are feeling that we also have to test those who are asymptomatic because they can potentially infect others. I can't tell you the final decision on that.

For your hospitals, what I can say is to try to track the people who are infected. Technology can help. There are apps that track where people go, where they stay, and who they visit.

I think South Korea is doing a very good job in terms of isolation, segregation, and testing.

Has this forced you as a subspecialist in oncology to work outside of your usual field and basically become a generalist, or to be a part-time emergency room physician or pulmonologist? Or are you still exclusively focusing on managing cancer patients?

I work in a comprehensive cancer center, so we are trying to continue to take care of cancer patients. As I mentioned, we are designating COVID-19–positive centers and COVID-19–negative centers. In the negative centers, we then have to divide patients into two different pathways—positive and negative—because this is the only way to continue to take care of the oncology patients.

But I can tell you that in general hospitals, people are being converted to different activities to take care of these patients.

How are patients with cancer accepting these new challenges? Are they seeing this as being part of a larger community and accepting that there are potentially other patients with higher acuity? Or is there a lot of frustration that their cancer issues are now secondary and they may not get access to care?

What we see is that cancer patients are very resilient. They understand better than the citizens without cancer. So they are more with us than other people. But again, I think the most relevant point is to stay in touch with them as much as you can.

What are the key lessons for oncologists in terms of recommending or avoiding treatments for their patients in regard to risk for COVID-19 infection?

Right now we have very little information available. We know from the first data in Italy that 20% of patients who have died are cancer patients.

What we don't know is whether there is a treatment that can potentially cause harm—for example, the ibuprofen story. We need to understand which patients are most likely to have pneumonitis and which patients may be potentially harmed by the treatments.

We have to join forces. Hopefully each one of us has only a few COVID-19–positive patients, but if we all join together and share cases, maybe we can get some answers very soon.

Yes. I want to credit you. You've been one of the earliest and strongest proponents of bringing together an international community of lung cancer specialists and other physicians to share as much information as possible and create databases that we can learn from. Thank you for all you've been doing. I wish you and your patients all the best.

H. Jack West, MD, associate clinical professor and executive director of employer services at City of Hope Comprehensive Cancer Center in Duarte, California, regularly comments on lung cancer for Medscape.

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