The COVID conundrum: loss and lessons learned

I’m Joseph Ischia
I’m Nathan Lawrentschuk.

Joseph: And we are Talking Urology. Nathan, it has been a while. Some might say a slow 2 years of podcasts. What have you been doing?

Nathan: Not much… no really- not much. It’s madness now while we play catch up and I feel like a kidney with a post-obstructive diuresis- there’s a fair backlog to get through, and people just keep giving me half as much work again.

Joseph: Well, that is the management. So as Nathan’s metaphorical creatinine drops, it’s time to look back at the pandemic that was… is…. and probably still will be for a while longer. I am not talking about Essendon’s poor performances.

Nathan: That does hurt but the real culprit here is COVID-19.

Joseph: A coronavirus not like any other and certainly worse than the 18 that went before it.

Nathan: It’s time to take stock. Specifically, we’re discussing how it has impacted upon the provision and delivery of Urology and also Oncology services across the country and indeed globally. Has it all been bad news or have some important lessons been learned? Are any of the Covid-enforced changes in our practice likely to remain in place in the years ahead?

We’re privileged to be joined on the show today by two erudite voices on the issue, Professor Damien Bolton and Prof Andrew Weickhardt. We could spend the whole show enumerating their various stellar publications and achievements but in the interests of brevity, we’ll keep it simple. Damien Bolton is a Urologist and Professor in the University of Melbourne Department of Surgery at the Austin Hospital and is on the editorial board of the World Journal of Urology. Andrew is a Medical Oncologist and Translational scientist at the Olivia Newton-John Cancer and Wellness Centre and Associate Professor at the School of Cancer Medicine, La Trobe University. Many thanks for joining us gents. We’re very grateful for your time.

Nathan: The COVID-19 pandemic is undoubtedly the biggest ever challenge facing healthcare systems worldwide. It is generally believed that the pandemic will continue for months to years yet. The provision of urology care during the pandemic has been based on the availability of resources, the severity of a patient’s disease, the consequences of deferment of a service and the evolving dynamics of the pandemic. Service delivery has required extensive reconfiguration as outpatient urology, cancer services and emergency operating have required prioritisation with changes to operating practice and outpatient care delivery. If/when the pandemic ends, how will COVID-19 have transformed clinical practice?

Nathan: Let’s get right into it so Joseph. I might start with Andrew. Tell us Andrew, what were some of your biggest takeaways from the COVID period in medical oncology?

Andrew: I think to begin with, people overreacted a bit in the medical oncology field in early 2020, and I mean that by oncologists changing patient’s chemotherapy plans in the sense that if patients were on palliative chemotherapy, some patients were delayed for fear that they were going to become too immunosuppressed patients. Had sometimes chemotherapy changed from intravenous chemotherapy to oral chemotherapy as an alternative, thinking that that was going to decrease the risk of getting COVID within hospitals. But the actual 2020 wave was quite small in retrospect, so I think there was an overreach and there’s been a few studies around the world that have looked at this and clearly the first part of 2020, I think, most medical oncologists went too far in terms of some of the changes they made overestimating the risks to their patients.

Nathan: Okay, and so what have you done now?

Andrew: Well, we’ve moved back instead of, for instance, reducing access to clinical trials and reducing chemotherapy given intravenously. We’ve moved back to more a business as usual, where we now with vaccines, of course, given to patients have more confidence that we can deliver chemotherapy to patients and mitigate some of those risks. There have been several studies that looked at risks in solid cancer patients that have shown that they do respond quite well to vaccination, making antibodies especially after a second or third booster shot, even if they’re on chemotherapy and immunotherapy or on hormone treatment. We now realize that the group that are at highest risks are those patients with blood cancers like leukemias and lymphoma, and they have quite a poor response to vaccination, are at all higher risk of severe outcomes and bad outcomes with COVID. So, they need to be looked at it that completely different population from what we’re talking about in particular regarding urological cancers.

Joseph: Any good things to come out of COVID in your field and maybe the way that you approached medical oncology?

Andrew: I think we’ve moved rapidly towards telehealth and phone health, which has been beneficial to some degree for some of our patients. I look after patients who might drive several hours to get a PSA result or testicular tumor marker results, the results of a CT scan that are fit and healthy otherwise, that have no ongoing health concerns. It’s been great to become efficient in delivering healthcare that’s timely, so we can fit in an appointment very quickly and they can get on with their lives rather than wasting three hours with me. I think also, we’ve delivered here chemotherapy and immune therapy in the home and at the Austin hospital now have a service that moved more rapidly towards providing that service, which is convenient for patients. So, they’re two concrete things that are actually much better.

Nathan: Yeah, I think telemedicine or so-called virtual clinics have been a huge positive to develop from Covid. We see so many people in clinic who do not physically need to be there. Andrew mentioned men coming for PSA results or testicular tumour marker results but that is just the tip of the iceberg. What about all those guys coming back for annual scan results by way of AML or renal cyst or small renal mass surveillance? Or people coming back to tell us if their anti-muscarinic or Beta-agonist is working. Or to tell us if their antibiotic prophylaxis has stopped their recurrent UTIs.

Joseph: I agree and particularly that last one, I’ll often use the line- You’re breaking up, I’m losing you, I’m going through a tunnel. It’s a tough one to pull off on Zoom.

Nathan: You’re an idiot.

Joseph: At least I’ve been fully clothed unlike some of those viral zoom clips I’ve seen.

Nathan: I am dragging it back to the new normal. It’s crazy when you think about it. Of course, it doesn’t hold true across the board, but unless patients are coming in for a CT scan or a flow test or require a physical examination etc, they don’t typically need to come to clinic.

Joseph: Definitely mate. With all the technological improvements and cost reductions as well as the widespread popularity of high-speed internet and smartphones, there is no reason why patients can’t quickly deploy telemedicine from home. The benefits of telemedicine are obvious…convenience, access to care from a distance and lower medical costs. At the same time, it can reduce contact with patients and thus potential infection. Providers in quarantine or isolation can also theoretically continue to work with back drops from the Eiffel tower in Paris or to their favourite beach in the Bahamas.

Nathan: Couldn’t agree more. Now Andrew spoke about something about during the height of the COVID pandemic, we asked him how he might have changed his risk benefit analysis on some chemotherapy regimens?

Andrew: Yeah, so I think when we were very worried about COVID affecting our patients without any vaccination availability, there were a group of patients that may have had estimated life expectancy of three to six months in a range of different cancers, whereby they may have exhausted traditional chemotherapy or well-proven chemotherapy treatments. That group of patients I think changed. We changed the way we approached them and thought that the risk of having more chemotherapy was higher than any benefit. Actually, it was probably a good thing because it forced us to be more insightful into the reasons why we would actually give chemotherapy to these patients where they may only have a 10 to 20% chance of benefit. I think now that we’ve got past some of this sort of peak COVID anxiety times, it still makes me realize that a lot of those patients, even now that we’re out of it, probably shouldn’t have chemotherapy and that even though that they want active treatment, we should say to them that they’re much better off actually not having any active treatment if their prognosis is quite poor, their response rate is quite poor. Some of that probably sounds obvious to you as a surgeon, but I think many of my medical oncology colleagues and myself included always feel motivated by a desire to help but I think COVID has forced us to reevaluate what actually is truly beneficial to the patients.

Joseph: I think that is an excellent point. I think we have definitely got better at prioritizing quality of life rather than quantity in those for whom the life expectancy is very limited. And bringing in Damien now, I know you have some interesting thoughts on the whole thing. We’re on the back of 18 months or two years of COVID, what do you think are some of the biggest lessons that you’ve learned as a Urologist and as a head of unit in a busy public hospital?

Damien: I think something we’ve always taken for granted in urology in particular, running a urology department, is that without thinking about it, we’ve learned to become very good at engaging with bureaucracy, whether it’s the bureaucracy of the Health Department, the bureaucracy of the hospital executive or even hospital administration. There was perhaps more importance of this than ever during COVID. Perhaps the biggest lesson I’ve learned from COVID, is that as urologist and surgeons in general, were naturally born to this idea of having to engage with bureaucracy and having to engage with healthcare providers at all levels all the time. During COVID, when there were so many changes, so much pressure, so many constant adjustments, it became apparent that we can do this at a much more efficient level than most other people in society and I don’t think we make the most of it. We probably don’t use this to our advantage as much as we should in pushing government. Although we’ve now got good experience in doing so and I think we can do that much better, we probably don’t do it to the same extent that we could have in terms of making a point known through the community. We probably don’t do it to the extent that we should do in engaging with industry and because I think probably in the future, there’ll be greater opportunities for all urologists to put this into practice.

Nathan: Really fascinating take on things Damien. How about on a personal level, patient to patient? What were some of the key things you learned during COVID in having to cope with the changes that occurred during that time?

Damien: I noticed during COVID, that there was a latent level of anxiety that was present in so many patients, and even the ones who you’ve known for an extended period of time who seems strong and capable, they were clearly unsettled by the changes to the community and the changes to what were their normal activities

Joseph: Any surprising benefits you saw come out of COVID?

Damien: It was clear that the biggest benefit to me was that when the administrative systems were streamlined, the changes in care didn’t deteriorate. So, we’re very used to having multiple levels of people that we have to have response to, whether these be audit people, whether they be academic, whether they be in terms of efficiency in the hospital, most of these people were very distracted during COVID. They were distracted or they were reallocated to other roles in the healthcare system. So, there is clear evidence to me, based on what we achieved during COVID, that we don’t need the same degree of governance and administration that we’re subjected to in the public hospital. We achieved the same level of outcome with way less in the way of administration during COVID and that should be a model for the future. We’re all used to trying to find efficiencies in patient management, we’re used of trying to find efficiencies in terms of cost delivery and efficiencies in terms of better outcomes for the same amount of effort, and I feel that other aspects of the healthcare system, apart from the clinicians, should be held to the same standard.

Nathan: I love it. Giving some control and autonomy back to the medical practitioners, I couldn’t agree more. Wishful thinking though I fear. What about the financial impact of Covid? All the unprecedented and eye-watering millions, billions spent on vaccinations, PPE, ICU care, swabbing centres, public awareness campaigns, you name it. How do we pay for all that? Are cutbacks in other areas now inevitable?

Joseph: I don’t claim to be an economics professor Nathan but I think we should print more money or go fully crypto. I am not even going to charge you for that.

Nathan: These are uncertain times, but one thing I am sure of is that you will never be Australian treasurer.

Joseph: Well, we’ll see. But trying to predict what the health budget will hold over the next few years is a fair question. We could look at it from a different angle. This Covid pandemic has surely highlighted and emphasized that we need more investment in health, not less.

Nathan: One of the key concerns during the height of the pandemic was what will be the long-term effects of delayed diagnoses and surgeries. This is particularly concerning for cancers, but also the non- cancer conditions such as all the bladders that were obstructed for a further 2 years before TURPs.

The delayed cancer diagnosis or treatment issue will be fascinating to watch play out. I also wonder how much of an impact Covid 19 has had on training and trainees? Has residency training been compromised as the services had to be massively reduced and limited to nondeferrable cases? For long periods, we saw the suspension of all nonurgent elective surgeries, the delay of all residency examinations and the cessation of undergraduate clinical rounds, not to mention the cancellation of international meetings like the EAU and AUA annual conferences. We even had the redeployment of some of our trainees to other areas of greater clinical urgency.

Joseph: And not to forget our great friends at the SIU whose conference was also delayed. And I think it’s a fair point you made there. This has all been going on for over two years now and their training has still not entirely returned to normal. My worry would be the volume of cases in theatre and clinics that they have been exposed to. It has been massively reduced compared to normal. We all know surgery is an apprenticeship and you can only learn with case volume and experience.

Joseph: I guess the onus is on us as trainers now to help these guys as much as possible and help get them back up to speed as best we can. And let’s hope we can keep that speed above 50 mph, so this bus does not explode. Because I think I might explode if we go into lockdown again. So, thanks so much to Damien and Andrew for taking time to talk to us today. Many thanks to Nathan too for his assistance. We’ve been Talking Urology today with thanks to our sponsors Astellas. Thanks for listening. We hope you enjoyed the show. We still have some fantastic podcasts coming up so keep tuning in.

Written by Mark Quinlan and Joseph Ischia with your hosts Nathan Lawrentschuk and Joseph Ischia. Produced by Joseph Ischia and Cara Webb and thanks again to Astellas for the wonderful support with these podcasts.