Smilow and Yale Cancer Center Town Hall | February 3, 2022

February 07, 2022

Hosted by Dr. Eric Winer | Presentations by: Dr. Kevin Billingsley, Osama Abdelghany, PharmD, MHA, BCOP, Lisa Barbarotta, MSN, APRN-BC, AOCNS, and Cary Gross, MD

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00:00I wanna welcome everyone to this town hall.
00:03For those of you.
00:04Who don't know me, I'm Eric Weiner
00:07and I actually am the in place,
00:10and the new Yale Cancer Center
00:12director and physician in Chief
00:14of of Smilow Cancer Hospital,
00:16and I'm really thrilled to be here.
00:19We have a great program today.
00:22I just want to make a few comments.
00:23First and foremost,
00:25I I want to thank Nita,
00:28who served in a remarkable way
00:32as the interim director.
00:35Between Charlie Fuchs and me and we
00:38all owe her just in an incredible
00:42incredible thanks for all that
00:46she has done and hopefully Nita
00:48will continue to remain very
00:50involved in the Cancer Center.
00:52But again, thank you, Nita.
00:56So I've actually officially been on
00:59the job for this is my third day my
01:03my about a third of our possessions
01:06arrived in an apartment today,
01:08so a good sign means that I'm settling in.
01:13And it's been a great three days.
01:16In truth,
01:17I've really been working behind the scenes,
01:19or maybe not so behind for the past
01:21two months, and I've seen many,
01:23many of you in lots of meetings by zoom.
01:27I have felt over those two months
01:29that I've been drinking from a
01:31firehose and I'm now I think I feel
01:33like I'm drinking from 2 fire hoses,
01:35but I seem to be managing so far.
01:39I have been incredibly impressed
01:42by everyone I've met,
01:43and all that is going on here.
01:45It's really quite remarkable,
01:48but I'm well aware of the many
01:52challenges that exist and the fact
01:55that the job is going to take a lot
01:57of hard work and it's going to take
02:00a lot of hard work on my part, but.
02:04On all of your parts, as as as well.
02:08I really believe that we can take
02:11what is remarkable talent here in
02:14basic science and translational
02:17science and population science.
02:19And also in clinical care and build
02:23a that truly world renowned program.
02:25A place that's my go to place for patients,
02:28not just patients who live in Orange
02:30and Milford and all over Connecticut
02:33but throughout the region throughout
02:35the country and even around the world.
02:38And I actually believe that Yale
02:41has truly limitless potential.
02:44At the same time,
02:46I have and this isn't just the
02:48past three days,
02:49it's over the past two months I have been.
02:53Really impressed by the
02:56commitment to diversity,
02:58both diversity in terms of the
03:00makeup of our faculty and staff,
03:02but also in terms of the commitment
03:05to serve people who are somewhat
03:08less advantage than others.
03:10And Yale is way ahead of that
03:13compared to many institutions.
03:15Certainly many institutions
03:17that I'm familiar with.
03:20It's.
03:21Gonna take a lot of teamwork in
03:23the months and years ahead.
03:26We all have to be on the same page
03:28and rowing in the same direction,
03:30which doesn't mean that everybody
03:31always has to agree all the time
03:34and and disagreement and dissent
03:36are really helpful to move an
03:38organization forward. I actually was
03:41never a camp counselor as a kid,
03:43but I think one of the things that I
03:45do better than most is not most people,
03:47but most other things that I do is being a
03:50camp counselor and bringing people together.
03:52And so I'm gonna do my best to bring
03:56you all together over the course
03:59of the the months and years ahead.
04:03So we'll get to the the topic
04:06of the town hall in the second,
04:08but I just want to ask you all as I
04:11start to come along on this journey
04:14and come to build a very special Yale
04:17Cancer Center and Smilow Cancer Hospital.
04:20I think we can.
04:21We can really do it and I'm totally psyched.
04:24And so, without further ado,
04:26let's let's get to our presentations.
04:30We have 3 today.
04:33The 1st is a clinical update from Kevin
04:37Billingsley, our Chief Medical Officer,
04:38and I think we're in a has slides
04:41that she's going to share.
04:42And Kevin, it's all yours.
04:52Thank you Eric.
04:53It is so I I also want to join you and.
04:59Really, extending my gratitude
05:01to Doctor Ahuja, and of course.
05:07Extending all of our warm
05:09welcome and good wishes to you,
05:12and it's just delightful to
05:13have you here and have you on
05:15this virtual podium with us.
05:22You know I'm going to spend most of my
05:24time doing this in this clinical update.
05:27Just reviewing where we have been
05:31as partly an organization but partly
05:34a cancer care enterprise with our
05:38our steps along the COVID journey,
05:41and it has been quite a ride
05:45and if I leave you.
05:48And I leave our community with no
05:51other message today the message
05:54should be that I think we all
05:57need to be extraordinarily proud
06:00of the work that we have done.
06:04Not only caring for our cancer patients,
06:07but the contributions that we as a
06:09cancer care enterprise have made to
06:12the entire health care system and
06:14caring for cancer patients throughout
06:17Connecticut and the Northeast.
06:20And it's all share at the end.
06:22Those contributions have been
06:25substantive and important.
06:28So to start with, these are our the
06:31hospitalization rates and death rates.
06:33That really show what we've been
06:36through in the past several weeks.
06:38You know, everyone knows that we had a
06:41really bad first wave in March 2020.
06:44We had an additional peak during
06:47the Delta variant.
06:49Things were quiet over the summer and
06:53then a meteoric rise in case rates,
06:56hospitalizations,
06:57and even although Omicron was less lethal,
07:02still a significant.
07:04Increase in death rates just
07:07during this past month.
07:09And fortunately,
07:10we seem to be on the tail end of that.
07:15Next slide.
07:21So I think most in the audience are familiar
07:25with the kind of trajectory of these
07:28variants right up until early December.
07:33Delta was the dominant variant in
07:35the state of Connecticut, you know,
07:38and it is breathtaking how quickly
07:40the Omicron variant took over in
07:43Connecticut in the northeast,
07:45and the S gene target failure is kind of
07:49the the marker for Omak, Ron, and and.
07:52These are data specific from our hospital,
07:56and I'll share that.
08:00These slides are are courtesy of Doctor
08:02Martin LO from infectious disease.
08:05So as you can see,
08:05as we entered into January very quickly,
08:09Omicron became the dominant variant
08:11in our hospital, really suppressing.
08:16Oma Cron dealt at a very low
08:19levels and we had test positivity
08:23rates around 20%. Next slide.
08:30So these are the hospitalization
08:32rates throughout the the system.
08:36Across the health system,
08:38we went up to over 700 patients
08:41as of today for this system,
08:44we're down to about 200 and
08:465255 patients in this hospital,
08:48Yale New Haven Hospital.
08:50We went up over 450 patients.
08:53We did briefly exceed the peak from
08:57the first wave in March of 2020.
09:00Now we're down to 134 patients
09:03and every indication based on.
09:05Wastewater and testing and other
09:08leading indicators is that that
09:11rate of inpatients will continue to
09:14fall in the coming days and weeks.
09:17Next slide.
09:20So one of the things that
09:23I was most impressed by,
09:24and I think great credit needs
09:26to be given to all of our teams,
09:28is that throughout this massive surge,
09:32we continued to really give cancer care and
09:36cancer treatment in an uninterrupted way.
09:39These are our visit volumes by type,
09:41including new patients and return patients.
09:44You can see we have our, you know,
09:47annual dip that we anticipate right around.
09:50The The the Christmas holidays
09:54and then very quickly.
09:56Even though we had soaring
09:58hospitalization rates and we were
10:00pivoting towards a Tele health approach,
10:03we maintained our visit volumes
10:06really throughout January.
10:07There's a brief dip right around the
10:11peak of the the surge in mid January,
10:14but as of the last week in January,
10:16we're right back up at our at
10:19our baseline volumes.
10:20Next slide, please.
10:24These are our volumes bimodality.
10:26You can see we drop down around
10:28Christmas quickly back up,
10:30but immediately within a week.
10:32We had implemented and pivoted
10:34back towards a very robust
10:37telemedical health presence and we
10:41had very strong infrastructure in
10:42place to the hard work of many,
10:44many people to get our patients
10:47seen using virtual technology.
10:51Next slide.
10:55These are new patient visits
10:57both in person and video.
10:59You can see that we are able to
11:02accommodate many of our our new
11:04patients through a video visit
11:06platform and prevent them from coming
11:08into the healthcare environment.
11:10And as things have started to wane,
11:12I think we are slowly transitioning
11:14back more towards in person.
11:16Next slide.
11:20One of the things that is incredibly
11:23important for our patients is that
11:26they continue in an uninterrupted way
11:29with ongoing cancer chemotherapy,
11:32and I'm really proud of these numbers.
11:35We don't have data for the month
11:37of January from our Smilow St.
11:39Francis site, but you can see that
11:43there was really no substantive
11:45interruption in our infusion operations
11:49throughout the January surge.
11:51Next slide.
11:55One of the things that was most
11:58challenging during the primary
12:00phase of the pandemic was delays
12:03and cancellations and surgery.
12:08We did have some delays in
12:10surgery and a few cancellations.
12:12I will say that the vast majority of these,
12:15particularly you can see this drop
12:17in surgical volume in mid January
12:20was related to patients or family
12:23members suffering from COVID
12:26related illness and volunteering,
12:28voluntarily delaying their procedures.
12:30We really were able to continue
12:34in an uninterrupted way for all
12:37of our major cancer and surgical
12:40oncology operations and hats off
12:43to all of our perioperative teens
12:46who continued to care for patients.
12:49And this occurred at a time when
12:51many of our staff were dealing with
12:55illness themselves in a rotating way
12:58so very pleased with those results.
13:03Radiation oncology yet another
13:05key operational area where we
13:08continued to forge ahead without
13:11significant treatment interruptions.
13:12Lots of cute kudos and gratitude to our.
13:18All of our radiation oncologists,
13:20as well as our therapists dosimetrists
13:23and physicists who all managed to continue
13:26to keep patients coming in to their
13:31daily treatments without interruption.
13:34So before I go on to the next slide,
13:37I wanna share some data that is
13:40not really is being discussed
13:42at the health system level,
13:44but is not available in a printed,
13:47printed or public form yet.
13:50But I think it is data that speaks to the
13:55heroism of our of all of our clinical teams.
13:59And it has to do with the fact that over
14:02the past month our health care system.
14:04Has cared for the lion share of COVID
14:08patients across the state of Connecticut.
14:12Just to put some rough numbers to this.
14:16We've had about 17,000 COVID
14:19discharges in the Yale New Haven
14:22Health system in the month of January.
14:25Our closest
14:30colleague in this arena, another major
14:34health care system in the state,
14:36had about 11,000 discharges.
14:40So in terms of volume and access.
14:44We were far and away the leader in the state.
14:48But perhaps most importantly,
14:50through the efforts of our teams
14:53and through the implementation
14:55of care of of care pathways,
14:58our outcomes were the best.
15:01Across the system,
15:02the mortality rate of patients
15:05hospitalized with COVID related illness.
15:08In January of 2022 was around 8%.
15:14At hospitals,
15:15other hospital systems across
15:17the state of Connecticut,
15:19the mortality rate for COVID
15:21related illness and January of
15:232022 ranged from 13.8% to 20%.
15:30So lots goes into this,
15:32but there is enormous reason for us all
15:35to be proud or oncology teams may not
15:38have cared for all of those patients,
15:41but our rapid transition to
15:44a hybridized environment.
15:45It was certainly one of the things
15:48that helped our health system
15:50absorb all of those patients
15:52during this very critical time.
15:54So incredible work, folks.
15:58Next slide.
16:02Last but not least,
16:03an important clinical change that
16:05will be rolling out that people
16:07will be hearing more about the next
16:09several weeks is the health system
16:11is transitioning to a high sensitive
16:14proponent assay for diagnosis of bio,
16:16cardial, ischaemia and myocardial infarction.
16:19This is in response to updates in
16:22the American College of Cardiology
16:25and HHS pain guidelines in terms of
16:29accurate diagnosis, there will be
16:31more information to come on this.
16:33There is like many areas there is already
16:36a care pathway that in has rolled out
16:40that incorporates this diagnostic test.
16:43There will be a series of three
16:45town halls that I would recommend
16:48to any of our practicing clinicians
16:50and you can see those dates here.
16:53There's also a question concerns and
16:56recommendations. Email, site and link.
16:58So more to come on on this.
17:01But this is coming forward quickly.
17:05So again, thanks to everyone and I.
17:08Think that.
17:12Sam maybe next Sam abdelghany. Sure,
17:16thank you Kevin. Good afternoon.
17:18Everyone at Lisa and I will present some
17:20pharmacy in clinical practice updates.
17:22We decided to join our slides together
17:25as we've been working very closely on
17:27many of the topics we present today.
17:30Next line, so first I'll start with an
17:33update on drug shortage and the good news.
17:36Now we usually bring to you that we are out
17:39of a drug or managing severe drug structures,
17:42but this time is positive all the way around.
17:44We are not seeing any critical shortage
17:47affecting any of the cancer therapies.
17:49Nothing new in this area and in fact
17:51it's it's it's positive because ABRAXANE,
17:54which has minimum of you know,
17:56has been in shortage since
17:58September due to some manufacturing.
18:00It should be.
18:01Ms was an allocation remain an allocation,
18:04but the team has been working very hard.
18:07To acquire any number of vials from any
18:11source as much as they possibly can.
18:14And because of this hard work we are
18:18able now to lift all the restrictions
18:20that we had in place early in October.
18:23So Braxton can be used in any treatment
18:27indication without any restrictions.
18:30We do ask that patient who have a
18:33reaction to tax saying that preference,
18:36at least initially to be.
18:37To re challenged before switching
18:39to ABRAXANE.
18:40If that's clinically possible.
18:42So we within our communication
18:44last week we just want to share
18:47the same information here as well.
18:48Next slide.
18:51One quick slide on COVID-19 therapies.
18:56This is an area that my colleague Nancy
18:58Buller been working on and leading the
19:00the work in Smile on outside smile.
19:02Oh, I listed that three drugs that
19:05are used today to oral medications.
19:08When Ivy. I'm not going to
19:10attempt to pronounce any of them,
19:12I just wanted to share with everyone
19:15today that the criteria for you is also
19:17have been expanding because the declining
19:19rate of positive cases over time which.
19:22Change the criteria based on the supply we
19:25have and a number of cases and now we are in.
19:29Very good place that allow us to open
19:32the criteria to essentially match what
19:34what's in the EU A and I highlighted.
19:37I mean it's oppressive disease and
19:38I'm using suppressive treatment,
19:40so essentially all our patients will
19:42be eligible for this treatment now,
19:45which was not the case with a
19:48more restrictive criteria.
19:49That the other comment I want to
19:53mention about the oral drugs initially
19:54and we we use the apothecary as the
19:58main source of the oral antivirals.
20:02They continue to be the the major source,
20:04but not the only one.
20:05We are now identifying locations closer to
20:07patient homes in Rhode Island in New York,
20:10and we are hearing that the
20:13state will start looking at long.
20:15Long term care facilities and and other
20:17areas to have this medication available.
20:20So in terms of availability of
20:23COVID-19 treatment therapies,
20:24expanding access and now available to
20:28everyone and hopefully all our patients
20:31will have access that as soon as they need.
20:34Next,
20:35slide moving from treatment to prevention or
20:38prophylaxis and during the last treatment,
20:41we talked briefly about a V
20:44shield and new drug that was.
20:47Available to us with an EUA for preexposure
20:50poleaxes in our patient population.
20:53Anybody with immuno compromised or may not
20:56mount adequate response to vaccination.
20:59And if you recall there was a two IM
21:01injections in the same appointment followed
21:04by one hour monitoring period since the
21:08beginning of availability of the drug.
21:10We we've been doing a lot of
21:12work on creating patient list to
21:15identify who is the patient or
21:17the patient population that will.
21:18Most likely benefit we created a A
21:20therapy plan in EPIC we we have this
21:23model that was designed to distance
21:25decentralized the workflow have the
21:27drug available in every clinic and
21:30have the clinicians follow the normal
21:32process to order an IM medication.
21:35We continue to work through many of the
21:39workflow issues over the last week but then.
21:44And your information that made us
21:46really look at the recommendation and
21:49look away to simplify and disseminate
21:52this information to everyone.
21:55This information that we learned
21:56last week that our patient now are
21:59eligible for a new dose of vaccine
22:03and Lisa will go over the detail.
22:05I'm going to call it,
22:06but I'll call it booster kind.
22:08Avoid the numbers,
22:09the 3rd or the 4th or the 5th.
22:12But because now?
22:14Our patients are eligible
22:15for this vaccination
22:17that has impact on when you give FS SHIELD
22:20and how the the the vaccine without
22:23the vaccine will be effective or not.
22:25So in the next slide we have a busy slide
22:31that contain all the new recommendation,
22:33but I'm I'm going to try to hit
22:35up high level points initially.
22:37If a patient is not eligible for a
22:41vaccine or is deemed not responsive.
22:45To vaccination based on the
22:46treatment they get and for example,
22:48a patient on on reflex map,
22:50they should get treatment with every shield.
22:53It's the best available option.
22:55Vaccination is not an option here and
22:57that the drug will be available to them
23:00for our patients who are eligible for
23:03vaccine vaccination is the priority here.
23:07Every shield is not a replacement
23:09for vaccination,
23:09so we want this patient to get their
23:12booster dose five months after.
23:15The primary series and Lisa will go
23:17over the details of definition in
23:20in a minute after the vaccination.
23:22We we are asking for the team to
23:27check spike anybody level 2 weeks
23:29after and depending on the level if
23:32it's less than two ten which we add
23:35designating as not adequate response,
23:38every shield would be an option.
23:40If we have a patient who is eligible
23:43to the vaccine but they are not due
23:45for that dose for 45 days or more,
23:48they are eligible for every shield
23:51at the tire is low.
23:53And they can schedule the vaccine
23:55at later time.
23:56One group of patients that we talked
23:58a lot about what can be available to
24:01them about a patient who received
24:03as an initial dose of J&J vaccine,
24:05followed by a second dose of M RNA vaccine.
24:09Those patients.
24:12Are not today there is no recommendation
24:14from the CDC on any additional vaccine doses,
24:18so for them the recommendation is
24:20to check the spike and everybody on
24:23level 2 weeks after the second dose,
24:25and again based on that level we.
24:29Maybe she can be an option,
24:31so really that the high level vaccine,
24:33eligible or not,
24:34and then we have specific criteria.
24:37This recommendation will be
24:39disseminated in multiple format.
24:41We are working on a care pathway,
24:43so it's going to be built in any order
24:45and until that finalized the drug is
24:48available today in all our clinics a
24:52couple of things before I turn over
24:55the slide to Lisa we we did a lot of work.
24:58Also on simplifying that criteria.
25:00So we still have tier one and Tier 2.
25:03We're gonna simplify that and all
25:05our patients will be eligible today
25:07without looking at the specific
25:10therapy they are getting.
25:12And the other work that we're doing
25:14is collecting data on vaccines
25:16and antibody levels,
25:17and hopefully that will give us information
25:20that guide decisions down the road.
25:23So we we're trying to capitalize on
25:25this opportunity to learn more about
25:28vaccine response in our patients.
25:30With that, I'll end. I'll turn over to Lisa.
25:34Thanks Sam, we wanted to just level set
25:37some vaccine terminology and there's
25:39efforts across the health system to
25:41standardize how we're referring to
25:44the primary vaccine series and any
25:46additional doses moving forward.
25:48So I wanted to just start with defining
25:51what we consider primary vaccine series.
25:54So for healthy immune competent patients,
25:56that would include two doses of
25:58an Mr AM RNA vaccine series,
26:01satisfies or materna for one dose.
26:04With the J&J vaccine for our
26:06immuno compromised patients,
26:08that primary series is defined as
26:10three doses of an M RNA vaccine.
26:13Either Pfizer or Moderna.
26:15So I'm really not thinking of our
26:18immuno compromised patients as
26:20getting 2 vaccines plus 1/3 dose.
26:23Some have referred to the third
26:24doses of booster.
26:25We really want to move away from that
26:28and really think about the terminology
26:30being primary series as three doses
26:32for the majority of our patient population.
26:35And then the terminology of booster
26:37will be used to to describe any shot
26:40that's given at least five months after
26:42the completion of the primary series,
26:45and that would be either 3 doses
26:47for immunocompromised patients,
26:49or two doses for immunocompetent
26:51so immunocompromised patients who
26:52have completed their primary series
26:54and received the three shots of the
26:57M RNA vaccine series are eligible
26:59for a booster of that scene vaccine
27:02five months after the completion
27:04of their third shot.
27:05If they haven't received
27:06their third shot yet,
27:07their recommendation is that they
27:09complete their primary series,
27:11get their third shot,
27:12and then five months later receive a booster.
27:15So we're hoping that kind of
27:19standardizing and socializing the
27:21terminology will help simplify some
27:24of the guidelines moving forward.
27:27Yeah, we'll go ahead and yeah,
27:28I just I'm not gonna go
27:29through this in detail.
27:30This is more to just remind people
27:32that we do have a resource,
27:34a health system resource,
27:36which is called the COVID-19
27:37vaccine decision table.
27:38This is retrievable from the COVID
27:41Intranet website and it they are
27:44actively updating this to align with the
27:47terminology that I just outlined for all
27:49for the group and it has age specific.
27:53Criteria for each vaccine type and
27:57will be updated with the booster
27:59dose information as well.
28:01Next slide.
28:04Again,
28:04just a reminder in that same document,
28:06it also has an appendix that
28:09outlines the definition of
28:10immunocompromised conditions that
28:12qualify for A3 dose primary series.
28:15I won't go through this in detail,
28:17but is more to just remind people that we
28:20have standard definitions for these groups.
28:23And then I think there's one last slide
28:26just to also share that the health
28:29system vaccination scheduling website
28:31has also been updated to standardize
28:34the language as I just presented it and see.
28:37I'm also confirmed that CVS is
28:39using very similar language,
28:41so you can see here.
28:42It should be very clear when
28:45you go to schedule that.
28:47You're either scheduling a third
28:49dose because you're immunocompromised
28:51and completed your second dose
28:52at least 28 days ago.
28:53Or you're scheduling a booster dose and
28:56have completed your second or third dose.
28:58If immunocompromised at least five
29:00months ago, so we're hoping these
29:03efforts will make it a little bit
29:05easier for patients to understand
29:07what they're signing up for.
29:09And I've also heard from some that
29:11my chart reminders are also going out
29:14to people who may now be eligible.
29:17For their boost booster,
29:18I think the timing of this is because
29:21the majority of our patients.
29:23Started to receive their third
29:25doses in August,
29:26so we're right approaching the five month
29:28park for a large number of these patients.
29:32I think that was the last slide.
29:34Thank you.
29:35So before we turn this over to Carrie,
29:39there are a few questions about
29:41vaccines that I think it probably
29:43makes sense to answer now.
29:45So first, in terms of the the concept of.
29:51The primary series being three shots
29:53for an immuno compromised patient.
29:55Does it matter if that third shot
29:58is was given five or six months
30:01after the first two? No, no,
30:03it's at least 28 days after,
30:06but if they haven't received it and
30:07I think you know in that scenario,
30:09I think the language is a little
30:11maybe a little bit arbitrary,
30:13but I think the importance is is that
30:15they complete their three doses and
30:17then they they can't get a booster
30:19after they complete that series.
30:21OK, and then the the booster would
30:23then still be five months later.
30:25Yes, yeah, exactly.
30:27And two more questions.
30:29Are you recommending a
30:31second booster for anyone?
30:39Not at this time that I can can think about.
30:41I think that's our next like we're
30:43trying to get through this initial
30:45push and then I think the next step
30:47is figuring out what's the next.
30:49You know, what's the next step after
30:52that initial booster is is given?
30:54And Sam, do you look like you wanted to add?
30:57I just want to point out that what
30:59we presented today is specific
31:01to patients and not employees.
31:02I think there was one question here.
31:06And and in terms of the definition
31:10of immunocompromised patients,
31:11and you had a slide that that addressed that,
31:14and you had on that slide
31:17chemotherapy all chemotherapy is,
31:19of course not the same, and,
31:21for example, would you consider a
31:24woman getting keep side of being a
31:28not a very immunosuppressive therapy,
31:30or a man for that matter,
31:32as being immunocompromised and needing that?
31:36That third vaccine is a primary series.
31:39Yeah, so the CDC used a pretty
31:42broad definition and I think our
31:44guideline in that appendix was
31:46in some sense and attempt to stay
31:49consistent with what the CDC outlined,
31:51but agree there's a lot of variety
31:54within the groups listed on that
31:56slide around level of of some you
31:58know or degree of immunosuppression.
32:01And finally a question and
32:03I'm just going to read it.
32:05Is the Moderna Rooster a full
32:08dose of vaccine or a partial dose?
32:11And if an immunocompromised patient
32:13received a booster as a third dose,
32:16and if the booster is a partial dose,
32:18what are the recommendations?
32:24I actually do not know the
32:26answer to the first part.
32:28If it's whole or partial.
32:32Sam the booster from Moderna is
32:35half half half of the dose. So
32:39it so if a patient received 2 doses of
32:42Moderna and what was thought to be a
32:45Moderna booster which was half dose and
32:48is immunocompromised, is that adequate?
32:55Yeah, I don't. I don't think we
32:56have a lot to guide us in answering
32:58that other than they should get up.
33:00They should get a booster
33:01dose when they're eligible.
33:02I think Doctor Seropian's were phoning a
33:04friend and he's a concurring with that.
33:08Uh, yeah. There is no official
33:12reach in this circumstance.
33:14They should get a fourth dose.
33:17I guess if they're if they're really,
33:19truly immunocompromised. OK.
33:25So thank you very much,
33:27Sam and Lisa and Kevin,
33:30who I didn't get chance to thank.
33:31And now we're going to turn
33:33this over to Kerry Gross,
33:35who I believe is giving us an
33:38update on the Center for outcomes,
33:41public policy and effectiveness
33:42research or or copper.
33:43And just to point out that carry
33:47mentors multiple people in oncology
33:51and has multiple cancer researchers.
33:55As part of copper,
33:57so carry the floor is yours and
33:59you're gonna share your screen.
34:14Can you see that? My slide.
34:18Alright, so I'm wanted also to.
34:23I have to say welcome Eric.
34:25We're excited to have you here and
34:27I'm really honored to be presenting
34:29on the first town hall and.
34:32I was going to start by describing the
34:35copper center and a little bit of a
34:38description about what outcomes research is,
34:41because for many people it's a type of
34:44research that they're not familiar with,
34:47but actually everything we've
34:48been talking about on this call
34:50directly relates to outcomes.
34:52Research Sam and Lisa talking about,
34:55you know.
34:55Right now we're adopting these
34:57new antiviral viral therapy
34:59that we know very little about,
35:01talking about rationing.
35:02You know accessing these therapies when
35:05there when there's very low supply.
35:07Kevin talking about our high volume
35:10up for COVID our high volume
35:12hospital and how we seems like
35:14we may have been offering better
35:16outcomes for our patients.
35:18So all these things,
35:19adoption of new therapies looking at
35:22the way we're delivering healthcare
35:24relation between volume and outcomes.
35:26This is all outcomes research already.
35:31So our cancer outcome center.
35:34My name is Carrie Gross.
35:35I'm a general internist,
35:37but I've been interested in
35:39cancer of my whole career.
35:41My main focus is on looking at the adoption
35:44and impact of new cancer therapies.
35:47So today I just spend a few minutes
35:49telling about what is the copper center,
35:52what's new, and what's next.
35:54Why does she care about it and
35:55why we hope to engage engage more
35:57people in the work that we're doing?
35:59So copper is a a pretty large consortium
36:04of faculty of Clinician investigators
36:07from throughout the medical school
36:09and the School of Public Health.
36:12So again, I'm a general internist.
36:14So I really look to all of my.
36:16Oncology colleagues, in particular to
36:18help to identify the salient question.
36:20So we have colleagues from medical oncology.
36:23As you can see here, Sir John OBGYN,
36:27neurology, public health, etc.
36:29So it's really an interdisciplinary group.
36:33So what do we try to do?
36:34So four things.
36:35So we first of all with this
36:38interdisciplinary focus,
36:40we engage in catalyze,
36:42really try to promote the sharing
36:44of ideas across disciplines.
36:46We aim to develop new research methods,
36:49which I'll talk about a little
36:52bit more briefly,
36:53we train Eric as you were mentioning, Inc.
36:57We engage and inspire new clinicians
36:59and cancer outcomes, research,
37:02and finally.
37:04Maybe one of the more important
37:06ones we're hoping to discover new
37:08information that will improve real-world
37:11that care and ensure equitable
37:13outcomes for patients with cancer.
37:16So I want to highlight that what
37:18we do is translational research.
37:20Often we think about translational research
37:23in the early phases from like 2021,
37:27when we're first translating new
37:29compounds or ideas into into the
37:32Cuban setting like these phase one
37:34trials or T2 translational research,
37:36which includes you know the clinical
37:39trials where we were really determining.
37:42Can a new agent or a new compound work.
37:46What we do in copper.
37:47We focus on this aspect of
37:50translational research.
37:51Both T3 and T4.
37:53So T3 research is what most people would
37:56think about effectiveness research.
37:58Does a practice or does a new treatment
38:02working in in clinical practice in T4 is
38:05is a population level outcomes research,
38:09so I want to highlight just a couple of
38:12exemplar projects and initiatives that
38:14we're working on in the copper center.
38:17One is a castle,
38:19which is the we're very big on acronyms,
38:22which is the cancer care and innovations lab.
38:25Really excited to be working on this with
38:28Karen Adelson over the past few years.
38:30So what do we do in Castle?
38:32It's kind of very closely
38:34aligned with the concepts that
38:36I talked about at the beginning,
38:38so we're really looking
38:40at real-world practice.
38:42Specifically here at Smilow,
38:43so we want we want to design and
38:46evaluate the novel payment and
38:49cancer care delivery interventions
38:51that we're seeing every day in
38:53dealing with as part of our clinical
38:55and administrative practice.
38:56In order to inform a practice
38:59here at Smilow and
39:00also to create generalizable knowledge
39:02for the US health care system.
39:05So just a couple really brief example,
39:08our projects here.
39:08So we looked at the new urgent
39:11care center to assess the.
39:12Impact of opening that
39:15center on urgent care use.
39:18We we're evaluating the oncology care model,
39:21which Yale it does participate in.
39:23It's a payment.
39:25An episode based Payment Reform initiative.
39:30Here you can see we looked at
39:32the relation between patients
39:34being involved in clinical trials
39:36and whether they their costs.
39:39Their overall cost of Medicare
39:41came in below target and we found
39:44that patients enrolled in clinical
39:46trials actually were more likely
39:48to have lower cost in this regard.
39:51This new hospitalist service,
39:53which is really an exciting
39:56development because the oncologists
39:58are up until very recently,
40:01had to be both inpatient attending and
40:04also covering the outpatient clinic.
40:06So here we looked at the impact of this
40:09new hospitalist service on several outcomes,
40:12including length of stay.
40:14And you can see that there's been a
40:17dramatic decrease in the length of stay.
40:19I was told to clarify this does
40:21not mean that the old system,
40:23the oncologist were not.
40:26That were not working hard actually is
40:28reflective of the fact that they were just.
40:29They were just.
40:30Expectations were too high and this new
40:33system is just much more patient centered,
40:35much more efficient or
40:36getting people out quicker.
40:38So Castle really is excited to work
40:41at this intersection of copper
40:43and smile allowed to develop
40:45rigorous evaluation approaches.
40:50That last 30 go end of life dashboard.
40:54So here we work with some
40:56of our external partners.
40:58In this case flat iron is
41:00a data science company.
41:01We used user data for research but also
41:04they work with us to help do some analytics.
41:07So here they've helped us to develop
41:10individualized end of life care
41:13provider reports with an idea to
41:15where the objective is trying to
41:17decrease aggressive and the life care.
41:20Same here, national benchmarks and just
41:23really briefly what's new couple things.
41:26Most importantly, we have a lot of
41:28new faculty joining Yale overall,
41:31and copper in particular, so I don't.
41:34I won't read all these allowed you,
41:36but many new faculty and trainees.
41:39Coppers never been bigger, happier than this.
41:42Now we now have three career development
41:47award, 3K award ease. In copper.
41:51We have a new FDA partnership.
41:55This other spent a couple of minutes on.
41:57The idea here is we're working with
41:59the oncology Center of Excellence
42:01to identify what what they're
42:03hoping we're hoping will be a new
42:06approach for drug evaluation.
42:08Specifically,
42:08looking at a new ways to investigate
42:11physical function in patients with cancer.
42:14So we're comparing love.
42:16Skip over here.
42:17So we're comparing 4 different modalities so
42:19there's everybody is going to get a Fitbit.
42:22There's about 200 patients with breast
42:24cancer or lymphoma that are getting
42:27at multi agent site cytotoxic therapy,
42:29so we're getting Fitbits the stopwatches.
42:32It's a 6 minute walk test,
42:34so we're going to watch them walk.
42:35They're going to do self
42:37assessments in their computer,
42:38and then there's going to
42:39be a clinician assessment.
42:40So working hand in hand with the FDA will
42:43be evaluating different approaches to
42:46assessing assessing physical function.
42:49And finally,
42:51some equity focused projects.
42:54Eric, you mentioned that the focus
42:56on equity here at Yale,
42:58and that's something that yeah,
43:00it is.
43:00If you look at this awful thing
43:02that happened at Brigham and Women's
43:04yesterday with his new Nazis out
43:06there protesting against people
43:08who are engaging in HealthEquity
43:10research now more than ever,
43:11it's important to support these efforts
43:14and we're really excited to be working.
43:18Closely with my seller and her team in
43:22the Center for HealthEquity and Cancer,
43:25so we're looking at macalik.
43:27Dyneins has an oral one looking at
43:30disparities and use of oral anti
43:32cancer agents and kidney cancer.
43:34We have a couple of small pilots
43:36looking at social determinants
43:38of health and some other pilots.
43:40Proposals finally,
43:41so I can go into a thank you to our
43:47external funders and enter the Cancer Center,
43:51NYC or internal funders.
43:55Carrying whirlwind tour
43:57that that would that was that was great,
43:59and in fact I have to say that the number of.
44:03Surgical, medical and radiation
44:05oncologists who are working in
44:07copper even astounded me and I knew
44:10there were a bunch there and I know
44:13that there are several coming of
44:15people that we've been recruiting.
44:17Pat La Russo has a question and
44:20it's it's an interesting one.
44:23So do you think that the cost for patients
44:26on clinical trials is lower because they
44:29have to meet performance status and
44:31organ metrics that are more stringent
44:34than patients in standard of care?
44:36And or two.
44:37They're typically followed much more
44:39closely than patients on standard
44:41of care due to safety imports.
44:44That's a great question.
44:46It's artificially lower, they can't.
44:49The in the OCM model the people
44:51enrolled in trials came in below
44:54target and the reason why is
44:56could not be a more simple one.
44:58You're more thoughtful answers
45:00and this is the real reason why
45:03is frankly the because the drug
45:04company gives the drug for free.
45:06So you're you're in this,
45:08so if you're in a checkpoint trial,
45:10you're getting the checkpoint inhibitor
45:11as part of being enrolled in a trial,
45:13so this cost saving to Medicare
45:15and then says policy relevant.
45:17It's called saving to the pair to have
45:20patients enrolled in clinical trials,
45:22but it's it's really because of that.
45:27Yeah, and Karen's adding that
45:29yeah and also and because of that.
45:31I don't know if you cannot say that
45:34other lower novel therapy drug costs,
45:36be it because the costs were being cast for
45:39being, I mean, the other thing that
45:41you can't account for is the fact that
45:43patients who enroll in clinical trials
45:45are fundamentally different and not
45:46even not even because of organ function,
45:49but because of their own choices,
45:51and then patients getting stated or care,
45:54and the doctors enrolling patients
45:56in clinical trials are are
45:58also somewhat different.
45:59So you know they're the wild card.
46:03Wild cards in this whole equation, and
46:05they often have more social support
46:07outside of the health care setting.
46:08And maybe they even have more support.
46:10They do have more, probably shouldn't.
46:12They probably have more support from the
46:14medical team than non trial participants?
46:16It's they're more plugged in,
46:17you know. Maybe that's
46:19the bottom line is we should keep
46:20enrolling patients in trials once.
46:22Once we get everything fixed here.
46:23With this with the CTO.
46:27Any other questions that people have?
46:32And Pat answered absolutely to me,
46:34we should continue to enroll in trials.
46:39Alright, well Carrie,
46:40I thought that was really wonderful.
46:43It's it's. It's great to see all the
46:46good work that's done and and and.
46:48Even more so, all the work that's being
46:51done related to health care disparities,
46:54which is is hugely important.
46:57I didn't realize that there had
46:58been a a demonstration in front
47:00of Brigham and women yesterday.
47:02I somehow missed that pretty even
47:05in the state of Massachusetts.
47:08So what can I say?
47:11Well, thank you all very much.
47:12We'll end a little bit early.
47:14Look forward to seeing everybody
47:17at the next town hall.
47:19And again, I'm.
47:20I'm really thrilled to be here,
47:23and I think that the staff unions
47:26presentations demonstrated why I'm
47:27thrilled to be here, so thanks.
47:30Thank you goodnight.