Virtual Oncology

Coronavirus is now disrupting the entire health care system, not just because of the burden of dealing with the actual disease itself, but because of everything else that’s had to grind to a halt. One of the areas where we really worry about things coming to a total stop like that is, of course, cancer treatment, which can often feel like a race against the clock even under the best conditions.

In this episode, Dr. Bobby Green, MD (Community Oncologist and Chief Medical Officer, Flatiron Health) and Dr. Sumit Shah (Oncologist and Head of Digital Health, Stanford Cancer Center) join a16z’s Vineeta Agarwala (physician and general partner) and Hanne Tidnam to talk about what is happening to oncology during the outbreak—how treatment is affected; what kind of clinical decisions oncologists and patients are having to make, and how they’re making them; the tech tools that specialists are using, and how they could improve; and what happens to oncology as a whole when it’s forced to go virtual.

Transcript

Hi and welcome to the a16z Podcast. I’m Hanne. We’re talking today about what is happening to oncology and to patients going through cancer treatment today during the outbreak of coronavirus—how treatment is affected, what kind of clinical decisions oncologists are having to make, and what happens to oncology as a whole when it’s forced in this moment to go so virtual. Joining myself and Vineeta Agarwala, physician and general partner at a16z are Dr. Bobby Green, MD (Community Oncologist; Chief Medical Officer, Flatiron Health) (the first voice you’ll hear) and Dr. Sumit Shah MD, MPH (Oncologist; Head of Digital Health, Stanford Cancer Center).

Hanne: We’re here today because coronavirus is now disrupting the entire health care system, not just because of the burden of dealing with the actual disease itself, but because of everything else that’s had to grind to a halt. One of those areas where we really worry about things coming to a total stop like that is, of course, cancer treatment, which can often feel like a race against the clock even under the best conditions. So, can we just start by talking about the biggest issues that your cancer patients are facing right now? How are they handling this?

Dr. Green: I’ve been sort of, I guess, surprised how much more resilience I’ve actually seen among a lot of my patients, and maybe it’s just because they’ve lived through so much uncertainty and gone through so much as part of their diagnosis that, you know, this is just one more thing. But I do think people have been remarkably resilient and, in fact, in some ways, a lot more so and maybe more laid back about this than some of my, you know, healthy friends and colleagues who haven’t had to deal with any health crisis.

There’s been a little bit of confusion about what does it mean for my treatments and uncertainty about timing, because I think none of us really know how long is this going to last and how long is the world going to look like this. And then, also, uncertainty about jobs and, you know, most people have their health insurances, we all know if they’re not on Medicare, their place of employment, and that’s a concern as well.

Dr. Agarwala: I’d totally echo what you said about resilience, Bobby. I had a patient last week who told our team that, you know, they can empathize with what everybody is going through, because it’s exactly what they felt like every time they had chemotherapy, that they’re suddenly susceptible to infection and that they have to be careful. And that was, like, their dominant reflection is that I understand why everyone is afraid, and I felt that fear myself, which was incredibly sort of empathic and a resilient thing for somebody to say you could have been worrying entirely about their own care.

Hanne: It feels like, from the outside, you’d imagine that would almost double that, you know, that you’d get sort of extra doses of that fear instead of almost being, like, inoculated against it because you’ve gotten so used to it. That’s really inspiring.

Dr. Shah: I will agree with you guys that, I think, most of our patients have been incredibly resilient and understanding of the current time, but I’ve also had a fair number of patients telling me, “Dr. Shah, my cancer can’t shelter in place, what do I do right now,” which is a very poignant point as well. So I think a lot of the patients are wondering about the timing of chemotherapy, “Should I initiate chemotherapy? Should I delay chemotherapy? What are the risks of doing so? Am I going to put my body at higher jeopardy for becoming immunocompromised? Or am I going to lead my body at higher risk for this coming back in the future?” So these are very difficult decisions to kind of make, And we don’t have a whole lot of data to help us support that decision-making capacity, so a lot of this is done on a case-by-case basis.

Dr. Agarwala: A lot of providers are discussing the Lancet paper about a relatively small cohort of 18 cancer patients who got infected with coronavirus across China and looking at outcomes and results there. You know, our data that are emerging like this factoring into your decision-making and into the decisions that cancer centers across the country are making, that data was, of course, limited, but it did suggest increased morbidity even among patients who are not actively immunosuppressed. How are you guys thinking about data like this and also about generating data within your centers?

Dr. Shah: We do, in general, think that cancer patients are probably more susceptible to viruses in general. they’re also more likely to get more serious complications. So I think we do have to be very ginger about what types of treatments we’re giving our patients, and we know that, for patients who are at higher risk for complications, we may be able to give them more support in terms of medications that can maybe decrease the risk of their immune system being compromised. So I think it is a valid concern, and I think that most of our treatments can affect patients in terms of their immune system. And we have to be very cognizant of how we’re treating those patents.

Hanne: So let’s get into those kinds of clinical decisions that patients are facing right now. There must be an enormous amount of gray area. Is there any kind of broad framework in place, or is it really on a case-by-case basis?

Dr. Shah: We broadly categorize treatments in terms of curative intent versus palliative intent. Curative intent meaning that you’re initiating chemotherapy or immunotherapy or any surgery, for instance, to be able to cure that patient from cancer. Palliative is thinking about treatments more in terms of improving patient’s symptoms or helping them to live longer, but we know that, for the majority of these patients, they won’t be able to be cured from this condition. So there had been some larger frameworks about saying that, for patients who are undergoing curative intent chemotherapy that we should go forward with that because the risks of recurrence could be, you know, causing a great deal of harm for those patients. However, for palliative patients maybe we should be a little bit more ginger about starting chemotherapy, which may dampen their immune system in the short run while we’re facing a higher risk from coronavirus.

Dr. Green: I think almost everything we do in oncology is looking at, you know, risks and benefits of various treatments, and I think, you know, most decisions we make are based on that calculation. And what’s so interesting now is you have a whole new set of risks with COVID, right. Some of that is, like, you take a risk by walking out of your house in the morning, which certainly wasn’t the case. You take a risk by walking in the clinic. You know, we take for granted that if someone gets sick and needs to go to the hospital, we have a good hospital for them, but if someone needs an ICU bed or needed a ventilator for something, is that going to be available? So, you know, spend a lot of time just trying to think about these risks, a lot of which are, you know, very uncertain in how those play into those treatment decisions about starting someone on adjuvant therapy or starting someone on, you know, palliative therapy.

Dr. Agarwala: Several of the guideline organizations that guide cancer care in this country, like ASCO, have put out relatively broad statements outlining the role of coronavirus factoring into decision-making with respect to both curative intent and palliative intent chemotherapy, with respect to timing of bone marrow transplantation, for example, recommending that such a procedure potentially be delayed for patients, thinking about adjuvant therapy, but most of the guidance has left a lot of room for interpretation. And so I’m curious, how are you personalizing that guidance?

Dr. Green: I think ASCO has done a really nice job of, you know, responding to this and putting out information, but at the end of the day, at least from where I sit, most of the recommendations have been use your clinical judgment and take into account,” you know, again, going back to that sort of risk-benefit framework. So I’ll give you a couple examples.

I saw someone this week who was an early-stage lung cancer patient who I had seen at the end of February and we planned to give him adjuvant chemotherapy, and we just had our second discussion today, and you know, we went from the conversation about what’s the benefit of adjuvant chemotherapy and should we go through with this in February before any of us were really thinking of coronavirus, And then we had the conversation twice over the last week and a half, and the framework shifted, right. Like, it made sense to do it at the end of February both to me and to the patient, and it no longer made sense, because the absolute benefit that we’re going to see for this when you compound it with the risk of “He’s going to need to come into the office frequently, it’s going to be harder and harder for him to stay isolated. What happens if he has a side effect or toxicity that puts him in the hospital? What are the additional risk factors for him being immunosuppressed because he’s having chemotherapy?” It just didn’t make sense to do that.

Now, he was a stage 1B lung cancer, and he was high risk, but it’s a situation in which, you know, you would go back and forth, to begin with, about whether to give adjuvant chemotherapy. I’ve had patients on bone modifying agents. These are drugs that are supportive drugs that are typically used in a variety of diseases, but while there’s benefit, the benefit accrues over a long period of time, and I’ve pushed those off because, you know, again, I don’t know that there’s a right or wrong answer, but in my judgment, the risk of them stepping out of their house and coming into the clinic probably doesn’t make sense.

Dr. Shah: Most practitioners would probably continue with the chemotherapy for patients who are young and otherwise fit and doing well with treatment. For patients where you’ve had a deep remission, now, one year, two years beyond treatment, for a lot of those patients, we can probably safely stop treatment at that time, and hopefully, the patients will continue to remain in remission. So it really depends on where the patient is and what kind of response they’ve had, but it also depends on the type of cancer they have. We know that there is a significant amount of heterogeneity between cancers, so not all cancers are graded equal by any means. So in each situation, we have to kind of do the risk-benefit calculation, and make sure that it’s in the best interest of the patient.

Dr. Agarwala: Are questions like this coming up at our tumor boards? Who is the group that you’re able to engage in real time on such difficult decisions for individual patients?

Dr. Green: Well, Vineeta, as one of my seven Twitter followers, you may have seen that I actually…

Dr. Agarwala: I saw that you crowdsourced that. Well done.

Dr. Green: Yeah, I crowdsourced the early-stage lung cancer question today. There’s just been…we have a multidisciplinary lung tumor board, Vineeta, where these questions have come up, a lot of curbsiding other docs, that’s been my experience.

I think what’s really interesting about the problems we’re facing is there’s sort of the art and the science of medicine, and this is really one of those circumstances that the art of medicine and judgment and how to apply sort of knowledge about data to great areas of uncertainty really comes into play. And it’s been intellectually challenging to do so.

Hanne: I’m glad you brought up Twitter, because I’m wondering, is that a viable kind of tool for you guys for crowdsourcing for even anecdotal, you know, data, advice, decision-making in this area?

Dr. Green: I’ve personally found the discussions on Twitter about this to be really helpful and really informative. So, to me, yes. And you, obviously, you know, you can only give…you have to be a little bit more general than you would like to be for PHI reasons, obviously. But I find it very useful.

I actually think that Twitter is probably the best source of medical information right now as oncologist. The majority of data that I’m actually receiving, I’m receiving in real time from my Twitter feed as opposed to waiting for publications to come out. So it’s actually been very, very helpful to have access to Twitter. It’s just been a tremendous communication tool from experts around the country and the world, in general.

Dr. Shah: We’ve been using our tumor boards to discuss a lot of these cases. As we were alluding to earlier that the data is very gray, we really don’t have a lot of information to base these decisions on. There have been consensus statements that have been put out into large publications from thought leaders across the world, and we’ve been using those as a framework by which to make our decisions at Stanford as well. But it’s still very much a gray area. It’s important that we employ shared decision-making with our patients to make sure that they also, you know, feel that they’re a part of this conversation.

Hanne: It strikes me that a lot of the decisions that you’re talking about making, you already are at a place of understanding to a large degree what you’re dealing with, what kind of cancer how it tends to behave. What about the patients that just found a lump, you know, and were coming to you for the very first step? What are the guidelines there?

Dr. Shah: The answer to this, in general, will really vary depending on where you are in the country, what kind of health system you’re in right now, and then where we are in the pandemic as well. while I think it’s true that most non-essential procedures and surgeries are being postponed, the suspicion for cancer does increase the prioritization of certain standard procedures. a new breast mass that you may feel in the shower, for instance, that would actually take prioritization to have that worked up. for patients or for men who have an increase in PSA over a slow period of time, they probably don’t need a prostate biopsy right away. So it really will vary on the type of cancer and the type of patient as well, but in general, patients with a cancer suspicion will probably be at a higher prioritization for getting their treatment done.

Dr. Green: So, at Flatiron Health, among our practices which use our electronic health record, OncoEMR, we’re able to track patient volume, and we saw, last week, a 22% drop in office visits across the network of practices. That also included a 16% drop in visits related to chemotherapy volume.

I think those are partially shock of the system, let’s reevaluate and see who needs to come in and who doesn’t. But it was pretty impactful. I mean, you know, our numbers across our network are very, very consistent, and then there was just this, you know, big drop last week. A lot of that is just going to be, “Well, hold on, we have to figure out what we’re doing.” I don’t think, necessarily, you’re going to see that much drop in chemotherapy, but I think there’s going to be a lot of really interesting data that’s going to come out of that to try to understand, you know, how this impacted cancer outcomes.

Dr. Agarwala: And to your point, Bobby, about kind of this being sort of unprecedented shock to the oncology care system for us to really see what kind of an impact happens on visit volume and treatment volume, and you know, some of that may even extend to outcomes. And it may be a really sort of fine-grained sensitivity analysis that we sort of have an opportunity to later look back at and say, “Well, what really happened if, you know, surgery was delayed by this period of time? And how did outcomes change? And what really happened if adjuvant therapy was delayed by this period of time? How did outcomes change?” You know, I think, I hope that, to some extent, some of that may be a silver lining in terms of learning from this crisis.

Dr. Green: The other sort of interesting thing that’s come out of this is it makes you spend a lot of time thinking how much you really need things that you thought you really needed. Like, you know, usually, this patient comes in and gets blood drawn, and you know, “Yeah, I’m going to do this telemedicine visit, and we’re going to skip the blood draw.” And I find myself saying, “Don’t worry, we can do it again in three to six months,” which sort of raises the question, did they really need that blood draw to begin with?

Dr. Agarwala: Yeah, or that scan or that physical exam. we’ve all felt sort of the sadness when we hear a patient describe their five-hour drive and then their, you know, hour-long wait in the waiting room and then their five-hour drive back, because it’s crazy to try to get a hotel room on the day of their visit, and this kind of logistical nightmare that many patients undergo in order to seek cancer care or seek second opinions or seek clinical trial evaluation. And I think we’ve all wondered, well, could some of this be happening more efficiently and in a more patient-centric way if we were to embrace technology in various ways? And sometimes a crisis is an opportunity for us to embrace that tech stack, and I’ve been sort of floored and amazed at how much of the Stanford oncology clinics are now sort of operating in the telemedicine sphere. I’d love to hear how you guys are managing this. Which patients are you bringing into clinic, which are you managing via telemedicine?

Dr. Green: I mean, I think the whole remote care telemedicine, virtual medicine, you know, I did my first telemedicine session, and I finished it, and my thought was, “Where have you been all my life?” It was, I mean, just phenomenal.

Dr. Agarwala: Your patient might have had the same thoughts.

Dr. Green: Yeah, I know, right? Like, that was easy. the easy answer is, you know, routine follow-up. So the patients who were coming in for routine follow-ups who didn’t want to reschedule or push back, I’ve done those over telemedicine, and that’s been relatively easy and relatively straightforward. I’ve also had a couple other patients who weren’t routine follow-up, but I wanted to try to keep out of the office. I’m thinking about a couple of patients, for example, with a disease called chronic lymphocytic leukemia who were on relatively new therapies were coming in to get their blood counts checked, so they weren’t just routine follow-ups. But given the changing circumstances, I felt relatively comfortable doing a telemedicine visit, making sure they’re okay, and pushing back their lab results for a few weeks. Where you obviously can’t do it is on people who need treatment, so people who need medicines to boost up their blood counts to keep their blood counts from getting too low. There are ways you can give those at home, but for patients who are getting it in the office, sometimes it’s just not easy to get that quickly done.

And then, the regulations around using FaceTime and Skype and other non-HIPAA compliant platforms has been listed, at least for the time being. So I’ve had a couple of circumstances where I’ve just FaceTimed patients to do those.

Dr. Shah: We’ve really dramatically scaled up the virtual clinics in our clinics in the last two weeks, which is quite ironic, because we’ve actually had virtual capabilities for over a year now. but it’s literally taken a pandemic to do this. utilization by virtual is around 5% to 10% of our clinic visits over the past year, but now, over the last week, it’s now greater than 60% of our visits are actually now all virtual, which is quite extraordinary, yeah. And really, we have this alignment for the first time, actually, where we actually have an alignment between providers, patients, and now even payers as CMS changed their laws in the past week to allow for reimbursement for telemedicine and virtual medicine. So that’s really changed the landscape completely, and so now we’re seeing a huge rise in our ability to deliver virtual care.

Hanne: So we had a podcast recently where we talked quite a bit about using virtual medicine and telemedicine tools for primary care and sort of triaging symptoms from your home. Are there particular pressure points that you’re noticing from the specialist point of view where things aren’t working so well, where there are sticking points or where the data flow gets messed up?

Dr. Green: Part of the thing, you know, oncology is, you know, you administer therapies to patients, and a lot of those therapies, it’s sort of hard to do in a remote setting. I think, from the oncology standpoint, that’s a barrier. The other area which I’ve sort of seen, and again, this has been in a limited experience, is, you know, there are often difficult discussions you have, and I think we’re all accustomed to delivering those difficult discussions in person and the ability to have physical contact. I think that’s been a tough part of remote oncology.

Hanne: Wow.

Dr. Shah: So much of oncology is an art form, as you were saying, And it’s really our ability to connect with patient which makes oncology so special and which is why so many of us went into this field in the first place. But it’s very difficult to do that virtually. As much as I love an emoji, you know, I think an embrace after giving someone good news is much more wanted by us. And we also know that the physical exam, as you were saying, is also very limited for these virtual visits. we do have some limitations, especially where the physical exam can be a little more important, such as gynecological cancers like endometrial cancer or cervical cancer.

Dr. Agarwala: What could be better? Like, if you had to brainstorm a feature list for the platforms that you’ve tried, what would help?

Dr. Shah: On our current platform, we can’t share screens nearly as easily. So I always try to tell a patient about a long nodule and he wanted to see it actually on his CT scan, so I actually had to take a mirror and show him his lung scans through the reflection on the mirror, which I thought was extraordinary in 2020 that we can’t do this quite yet.

Hanne: How about the sharing of information like provider to provider or specialist to specialist? That’s something that our partner, Julie Yoo, brought up on the last podcast as being, you know, still not seamless with the data flow of these telemedicine tools.

Dr. Green: Well, I mean, I’ll give you an example today that happened to me as one of my patients who I didn’t think I was going to need to examine said, “Oh, I have this thing on my back,” and turned around and tried to show me this thing on his back. And it was…which as an aside, there had been a lot of sort of comical technology-related things that have happened in the last week and a half too.

Hanne: Like, what? Like, I can’t even…would you put your phone on your cabinet and, like, turn around and take your shirt off? I can’t even really imagine how that…

Dr. Green: Well, like, this was one trying to turn around and show, you know, my patient trying to show me a picture of his lower back and called his wife in and not being able to see where he was. Another patient who just wasn’t really used to using the phone on his camera, and he kept putting his camera up against his ear so I could see the inside of his ear, but not the…you know. you assume that everyone in the world uses technology like you do, and you quickly find out that that is, you know, not the case. Like, people who don’t, you know, aren’t sure what to do with a hyperlink. So that’s been sort of interesting, but I’ve had some nice laughs with my patient around this as well.

So some of this are sort of growing pains and grow-out pains. But maybe, in the future, if a cancer patient was expecting a certain fraction of their visits to be over telehealth, you know, maybe that adaption curve would look different.

Dr. Green: Yes. So, I mean, I’ll just give you one example for a feature that would have been nice. So this patient, who I just told you about, who had this thing on his back, I couldn’t get a clear enough picture on the video. He actually took a picture of it with his camera and then emailed it to me. I looked at it. I thought I knew what it probably was, then went through a long and arduous process of communicating with his dermatologist who he was supposed to see next week and sending him the image. Boy, wouldn’t it have been nice if I could have taken the image right from the telehealth platform, sent it over to his dermatologist, and messaged his dermatologist on the same platform, “Hey, can you take a look at this and let me know what you think?” To me, it’s all, like, the biggest problem, from my perspective, to solve is not just telehealth, but I think everything is, you know, real-time or fast communication between clinicians, whether it’s colleagues or second opinions or docs you refer to. That’s the biggest pain point for me, which, you know, ultimately, could be solved partially with this.

Dr. Agarwala: a couple of the observations that I had watching some of these telehealth visits take place were just kind of how open and comfortable a lot of the patients seemed chatting over a video visit. my sense is that some of that is because applications like FaceTime and other video chatting applications are just so much more prevalent today that a lot of patients don’t feel like it’s quite as awkward as you might have anticipated. it was actually interesting to get a glimpse into how they’re functioning and what they’re doing and the fact that they’re running in from the kitchen, you know, you kind of get a sense, actually, of a patient’s mobility and comfort level with their ADLs, activities of daily living, in a way that you can’t sometimes get when they’re sitting on an exam table. So I think it’s been interesting to see that we might actually learn about patients in a way that is hard to do when they come to the clinic.

Dr. Green: Yeah. You know, Vineeta, it’s funny you say that. I mean, I, like, found one of the really useful thing to see people in their own environments and in their homes, one thing I have always liked to do with patients is I’ll ask them to bring in pictures of themselves, either when they were younger or before they were sick. And I was, you know, telehealthing with one patient, and she was sort of sitting in a desk. And behind her, she had like a million family photos all hanging on the wall, and I was, like…and I didn’t do it, but I was so tempted to say, “Hey, could we, you know, pull a couple of those off and let’s take a look at them?” But you really get insight that you don’t, and I’ve had, like…I literally had 2 patients, 30 seconds into the conversation, say to me, “Oh my god, I forgot to put on makeup.” And you know, you just realize, you see people different than you see them when they come into the office.

Dr. Agarwala: One space that we’ve all heard a lot of discussion about, actually, in the context of coronavirus therapy is our clinical trials that are now, you know, actively enrolling and I think a lot of people started thinking about what a clinical trial is and have heard of the word more than they might have before. But for cancer patients, this is the norm, right. A lot of our cancer patients are always thinking about a trial in the future or they might be on a trial now. We’d love to hear how clinical trial operations are affected by shelter at home orders for so many of our non-essential workforce. How is that playing out for patients on trials or patients considering trials?

Dr. Shah: The shelter in place has obviously hampered enrollment considerably. We’ve had a tremendous decrease in enrollment over the last couple of weeks, which is very understandable. Patients just don’t want to come to the hospital nearly as much. Adding to that is that a lot of trials are actually holding new recruitment to trials as well. So a lot of the crew was being held right now. For patients currently on trial, they are allowed to continue on treatment, and they are encouraged to do so. They are allowing for more deviations, I mean, that patients can skip treatments if they feel that they need to in order to protect themselves from this virus. So we’re starting to see that sponsorship trials are a lot more lenient than they were in the past. A lot of the trials with oral medications are still being continued, and the sponsors are also being a lot more lenient about shipping drug home so that patients don’t have to come into the hospital.

I also believe that this is going to cost us to reconsider the way that we do a lot of the clinical trials. It’s really necessary that you get that certain esoteric lab on day 52 of the clinical trial and make the patient come for 4 hours to do that. I think this will make us realize that a lot of the things that we’re doing are probably not as important as we used to think they are.

Dr. Agarwala: The FDA announced that, you know, they’re working on providing guidance to sponsors and trial sites to enable sufficient regulatory flexibility to allow trials to continue through this period to the extent possible while, of course, keeping patient safety paramount. What are some of the sort of tactical ways in which you think this guidance could play out? And in which do you think there might be more flexibility than there was before?

Dr. Green: I think the flexibility ultimately helps. You know, there is so much concern about not following protocols exactly to the tee and deviations to that that I think that flexibility is going to get people ultimately more comfortable with having patients on trial during this time. To me, certainly, it’s understandable why things are dropping off. I think it’s also, in many ways, tragic. You know, we, at baseline, don’t put enough patients on clinical trials. It’s such an urgent need, and it’s just disappointing even if understandable to see why that’s dropping off. you probably saw, I think, Pfizer made an announcement that they’re stopping accrual, except for life-threatening conditions. I don’t know if life-threatening applied to every cancer trial that they’re doing or not. for trials where, you know, assuming you have enough staff to keep taking care of patients, if you have a trial that doesn’t require visits outside of the standard of care, you know, I hope we’d be able to see those continue. One thing that was, you know, really personally very exciting to me is we have a lot, you know, community oncology does a lot of clinical trials, something that, I think, not everyone appreciates. And we’ve seen a lot of continued accrual to trials. We work very closely with one particular trial that we’ve helped do data collection for, and you know, we’ve seen practices, even in the last week, accrue four, five, or six patients to this. docs, despite adversity, get that clinical trials are important and are continuing to try to do it, you know, even in difficult times

Hanne: It’s interesting because, you know, going into this, I sort of, as an outsider, sort of naively thought that, at the broadest level, you know, the advice or the kind of thinking would be pause what we can pause safely. But it actually sounds like what you’re saying is keep doing everything that we can keep doing safely, is more the spirit.

Dr. Green: I mean, that’s my perspective, especially…I mean, it also depends on the file, right. So if you’re doing a clinical trial, which are often the case in cancer, whether it’s a phase 1 trial or a phase 2 trial for people with bad cancers who have run out of options, it’s difficult to continue those. But I think it’s appropriate, a lot of the time, to think about, “How can we make it work?”

Dr. Shah: We are doing an international cancer registry right now on patients with coronavirus, and this was an effort that was largely led through Twitter, actually, by recruiting other physicians from other institutions to capture all this data. And I do think that clinical trial data, especially randomized clinical trials, are going to be more difficult to do in the current era because of the regulation. there should be an importance placed on what we call real-world evidence, and this type of data would be very informative in the next several months as well as we’re going to get limited data from randomized clinical trials.

Hanne: Let’s sort of go back to where we started and think about what happens to oncology as a whole when it’s forced in this moment to go so virtual. What do you think is going to stick and what do you think we will let fall by the wayside when we finally get to move out of this moment?

Dr. Shah: I do think that virtual clinics are here to stay. I also think that we’re going to see a large shift away from hospital-based care and more toward home-based care. You really need your Infusion at Stanford or at your cancer center as opposed to the confines of your living room. I think, you know, if you look at certain examples, like for drugs that we’re using, lymphoma, for instance, a drug called rituximab, it’s an IV medication that is now being formulated to be subcutaneous, you can imagine a scenario where you had a digital safety lock on that syringe that could be activated by your provider after a virtual consultation to make sure that you’re labs look okay and that you are feeling okay. And so I think a lot of the stuff that we’re doing right now in the clinics can certainly be done at home kind of furthering the kind of the capabilities of virtual medicine.

Hanne: What’s the incentive to keep doing that after coronavirus goes truly away?

Dr. Shah: Patients, in general, actually prefer this. It’s amazing that after these virtual consultations, I’ll often tell a patient that, “Well, I’ll see you back in three months, hopefully here at Stanford,” and they say, “Well, Doc, actually, this worked out pretty well. Why don’t I see you back on the telephone, you know, on my cellphone in three months instead?” And I do think that we’re going to see greater use of digital health in public health and interventions as well in the horizon of public-private partnerships. You know, if you look at the countries that were the most successful in containing this epidemic, they’re all countries that employ technology as a very large part of their response. You look at South Korea using cellphone data to be able to do contact tracing for patients who are infected with coronavirus. You know, even Russia was using artificial intelligence and facial recognition to be able to enforce their quarantine, not suggesting that we do that by any means, but then you can even look at China that was using artificial intelligence to be able to diagnose COVID just from chest x-rays. So I think that we’re going to start seeing a lot more digital health in public health infrastructure, and I think that’s another thing to secure this day as well.

Dr. Green: Specifically around telemedicine, the genie is out of the bottle, and it’s going to be hard to sort of put it back again. You know, one of the things that CMS did that I think was really, really helpful was expanding the number of codes that you could use for telemedicine. I like to think that’s going to continue, because that just made the whole process much, much easier for clinicians to do.

I like to think that all of us having to go through the experience of really asking, “Do we really need these things that we always think we need,” just like sort of value-based care has pushed us in the direction to second guess things that we used to do. I hope that this does as well. And then, lastly, one of the things that this whole episode has caused me to reflect on, I’m fortunately healthy, my family’s healthy, and I was basically…we were all given news a couple of weeks ago that you have to stay at home, you can’t go out, your life’s going to be disrupted, and if you get this disease, there’s like, for me and my age group, there’s a couple percent chance that I’m going to die. And that was really, really hard news for me to take as an individual, and in my job as an oncologist, I give people news 10 times worse than that, every single day.

Hanne: Interesting, yeah.

Dr. Green: And they deal with it a lot better than I, you know, have dealt with this. So I like to think that, for all of us who’ve been lucky enough to be healthy, it gives us a little bit of perspective of what our patients go through.

Hanne: That’s wonderful.

Dr. Agarwala: The silver lining in my view from sort of a technology perspective is that it’s a pressure test of unprecedented scale for our system to navigate how to incorporate technology in different aspects of care, how to keep in touch with patients when they can’t come in to the clinic, how to make complex decisions that require coordination in real time with uncertain data between different specialists. because this is a time when, under this type of real pressure, that’s when these future lists are generated, and that’s when we realize what we need and we realize we need now And so I think that this pressure test is just going to actually be an incredible learning opportunity for a variety of sectors of digital health.

The other piece that I think is interesting, kind of zooming out of oncology, in particular, is just the increased awareness that’s occurred for diagnostics and infectious disease therapeutics. I think it’s given our public, our funding agencies, companies, investors, everyone across the board a deepened level of appreciation for how important anti-infective agents and preventive agents really are. And so I hope we’ll see a renewed investment globally in technology and that domain.

Hanne: That’s really inspiring. Well, thank you so much for all joining us on the “a16z Podcast.” And thank you for everything you’re doing for your patients every day.