 Okay, we're back real live. I'm Jay Fidel. This is Think Tech and this is a corona watch and we have today Randall Holcombe MD MBA at the Cancer Research Center In Japsum and we're going to talk to him about the immune system and cancer and how those things relate to corona violence It's not easy. It's complicated Randall. Thank you so much for joining us today. Jay, my pleasure So, you know, I guess the the first thing is the immune system is central in Coronavirus but the immune system is also central in in cancer So there must be multiple intersections. Can you can you can you drill down on some of those intersections? Sure, I think there there are many things related to the immune system for cancer patients that are important while we think about this coronavirus pandemic We know that patients with cancer tend to get a suppressed immune system. Most of that suppression of the immune system is due to treatment due to chemotherapy and Radiation therapy. There are a few kinds of cancer that in and of themselves suppress the immune system. Leukemia, for example, and lymphoma tend to markedly suppress the immune system But most of the more common malignancies such as breast cancer and prostate cancer, colorectal cancer and lung cancer Don't in and of themselves suppress the immune system that much But the immune system is markedly suppressed when people get chemotherapy and radiation therapy Our main concern is with the coronavirus is that patients with cancer who have a suppressed immune system May have much more difficulties with handling the virus infection than other patients Now, how does that reconcile with the notion that You know what what really hurts a coronavirus patient is the immune system overreacting to the virus in the lungs So if my immune system is suppressed, then maybe it won't overreact. Maybe that's a good thing I know this sounds ridiculous, but could that be a good thing? So the answer is yes, it could be a good thing or it could be a bad thing And I think we really don't know One of the things that we've done here at the University of Hawaii cancer center is we've signed on to a national study Which is led by a group at Vanderbilt And this study actually collects information about cancer patients Who are infected with the COVID-19? virus and tracks how people do and we submit all of that information into a large database So that we can try to ascertain What happens to cancer patients who ever suppressed immune system when they get this virus? I think we all worry that they might do worse Because their immune system can't fight off the viral infection But we do know that some of the damage to the tissues is caused by the immune response and so Perhaps that lessening of the immune response may in some ways be beneficial for these patients It's really hard to know and I think we don't have the information at the moment And that's why it's so important that we collect the information One of the other things that we found and I think you've probably heard on the news is that some populations are Much more severely affected than other populations across the united states And one of the things that We'll have the advantage of doing Here in hawaii is collecting information On a population that's particularly relevant to the people here in hawaii And is not information that's generally being collected across the rest of the united states So that's one of the reasons we thought it was so important for us to participate in this study Yeah, well, you know hawaii is a living laboratory of diverse cultures and and then dna and what have you and That could be very valuable As it seems to me that we need to know as much about how the immune system works In the in the face of uh covid as we can because ultimately am I right about this ultimately We want to be able to tune The immune system to do the right thing to fight the virus but not fight the body And if you can get it right down the center of the track that way by tuning it somehow Therapeutically or otherwise Then you can have the best of best of those two alternatives. Am I right about that kind of analysis? That would be great. I think we don't have the tools To fine-tune the immune system that well We do have medications that will suppress the immune system We have medications that will stimulate the immune system And understanding how to stimulate a part of the immune system and not another part is really difficult And I think we're not quite there yet from a scientific point. Okay, but hold that thought you never know these days What about what about the antibody thing? You know, we have antibodies and antibodies are part of the testing protocol now I although I doubt it's available in many places Um, and then you have antibodies from somebody who had the disease and maybe that can help somebody somebody else In fighting the disease Um, where where does that fit with the immune system and is it is it really true? Is it really useful? Well, I think antibodies are always good when you get infected with something you typically get antibodies You get some immunity for some period of time um, I think we don't know with uh, COVID-19 how long people will have immunity We do know that some common colds are caused by coronavirus And you will get immunity for a short period of time, but then it goes away And you can get that cold again from that same virus. So We're hoping that it's more long-lasting immunity that people get one of the things for cancer patients is that when Especially when they're under treatment and we affect the B cells with that's one component of the immune system that makes antibodies The Thing we don't know is whether The B cells will function normally to produce antibodies against this coronavirus And so we we don't even know if if cancer patients who get infected with coronavirus are going to generate antibodies at the same Rate as other people are I think that's something we're going to have to learn over time, but we don't know that at the moment One thing it strikes me is that you know, and it goes back to the the common flu um I mean the one that doesn't kill you necessarily Where where every year you have to get another another shot a whole fresh vaccine And that means that the virus is different year to year And that means to me and i'm i'm just going you know deductively here. That means the virus Has mutated. It's a different virus. Therefore you need a different vaccine a different You know dead virus. I guess whatever they put in a vaccine To deal with it. So if you tell me and I've seen this too in the in the media If you tell me that the antibodies From a person who has had covet will only last so long Say, I don't know say six months I'm just throwing that number out. That means within that six month period Something has changed It could be that the antibodies that you have available Lose their vitality in the six months. It could be the blood changes You know the carrier system that changes in order to make the antibodies effective for longer than a x month period But it also could mean That the virus that's coming down the pike Is mutating So at the end of that period of time we have another virus and the antibodies are only addressed to virus a But not virus b Is there any thinking about that? So I think corona virus is a bit different from the influenza virus influenza is uh very commonly known to Mutate fairly rapidly so that new strains appear Each year they're usually multiple strains of the influenza virus So the vaccine you get actually is is trying to provide protection for multiple different strains Not just a single strain. I think when we from what we know about corona virus from the sars epidemic That that you know occurred many years ago It doesn't have that same frequency of of mutating And we hope that that remains the case Because then we could develop a vaccine For covet 19 that Would hopefully be a single vaccine and could be used even if you had to even if you had to get it every year It could be the same vaccine that could be used Hmm. Well, that would be great. That would be great. That would be a good result Although As everybody says nobody knows exactly when that's coming down the pike or what it's and there are so many people in the world It was I saw a newspaper article today with all the candidates For that vaccine and a lot of candidates and you don't know what's going to happen You don't know whether the trials would be successful or what? But I wanted to ask you about the the plight of the cancer patient because it's a real plight So now you have cancer. That's scary. That's scary because it threatens your life And you have to deal with that and you know, you're in a sort of state of mind I'm sure you you've seen that many many times About how you know, you know your life Mortality Okay, then the bad news is that something Gives you coronavirus So if god, it shouldn't be me and it shouldn't be you but if I had a combination of those things I would be terrified Um What would is that a legitimate terra? I mean is it is it significantly worse to have both of them? Uh, and what happens to people who are faced with the double whammy like that? What what happens to them in the daily course of Dealing with doctors hospitals researchers. How do they react? So I think I think cancer patients are generally worried about possibly getting uh coronavirus They you know, they're they're fighting cancer That's difficult enough and then you throw another terrible illness on top of it I mean, that's a terrible terrible thing to happen to somebody what that has done has it has Uh directly changed how we're caring for cancer patients at the moment. So a lot of patients Don't really want to come into the doctor's office to get checked as often as they should get checked When they're undergoing cancer therapy They're worried when they come into the infusion center to get their chemotherapy They know they have to get their chemotherapy But they're worried because it's a hospital type setting or a doctor's office type setting and they're worried there may be other people Who have uh coronavirus and they might catch that from so we've had uh lots of Uh disruptions in cancer care related to this We're trying to do a lot of physician visits by teleconference which Is okay for some patients, but not okay for some other patients But we're trying to do that as much as possible We've been delaying Some appointments that we don't think are are critically necessary Some patients are having difficulty in scheduling surgeries for their cancer. So For many types of cancer for instance We often treat it up front with chemotherapy or radiation therapy and then follow that In four to six weeks with surgery. Well, that's not really an elective surgery Like getting a knee replacement that could be an elective surgery could be done this year could be done next year but But it's not an urgent surgery either and some patients have had some difficulties especially In the hard hit areas in the country in getting those types of surgeries scheduled Because going to surgery requires anesthesia that requires an anesthesiologist that requires a ventilator And those things are in short supply And so uh scheduling these surgeries is has been been quite difficult for many cancer patients That just adds to the stress of All of the journey with cancer The other thing that I really I think is very important as well and that that a lot of people aren't talking about Is that because uh, we have been delaying routine type visits and routine care a lot of people are not getting their routine mammograms And scheduled colonoscopies and things that are really important For cancer screening and to catch cancers early and to prevent cancers if possible And i'm worried about that because the longer that this goes on the longer those things are going to be delayed And i'm worried that we're going to have patients with more advanced uh cancer sometime Down the road because they've missed out on their regularly scheduled screening. So I think that's another aspect of COVID-19 that's affecting cancer patients or potential cancer patients That is a little bit unrecognized Something that we're really going to have to address moving forward and try to get people there screening in a safe way And you can have a double whammy there too. You could not screen So you have a great number of cases that require more aggressive treatment And then you can have a a curve that hasn't hit the apex yet a curve that's going up We can have that in a way. I hope we don't I don't think we will but it's a possibility And and then the medical resources are not available to you. So you have an increased number of patients And you have a decreasing amount of medical resources to treat them. What a combination of events This could this could happen So, you know I talking about You know About what we do about about solutions Two two questions. I want to ask you about that one is one is for the individual patient Who could screen who knows he asked the screen or she asked the screen? Then he should make she should make every effort to be screened, right? Even if it's a little scary to go into, you know, a medical office with people all around Um and screen. Maybe he should stick to stick to the protocol and get screen Wouldn't that be your advice my recommendation at the moment would be To not worry about screening today But to not put it off for more than a few months. So, uh Perhaps in the summer or the fall get the screening done But don't wait a year and don't decide to skip out on it altogether Okay, and what about situations where, you know, the medical community really doesn't have the resources It's it's kind of direct the resource to the more existential threat Which is uh, you know, the current coronavirus cases themselves I mean, you can make an effort of x units of effort or you can make an effort of y units of effort if you are a cancer patient Uh, how much effort do you put into that? Or do you just leave it to the system to carry you along and and find the resources when it's appropriate? What do you think? You know cancer patients do require a lot of resources, but uh They're pretty high on the list of of needy patients so I think that most centers, uh when they get past the initial problems with uh, a large number of uh, COVID-19 patients that they have to take care of Are are really going to try to address the cancer patients pretty quickly and much more quickly than uh, then Perhaps other elective health problems that people may have so I'm not too worried about that. I think all of the oncologists are are very worried about trying to make sure that We keep our patients on schedule as much as possible and we don't Impair their therapy. We know that treatment delays for instance or delays in initiating treatment for cancer patients Directly correlates with the mortality from cancer. So we don't want those treatment delays We want to try to keep things on time. We want to get people treated As best we can because we know we have the best chance of curing them if we can do that So I think it's going to be a pretty high priority to get uh cancer patient therapy Back on track as quickly as possible Yes, yes Uh, and and something you said, I mean, it's it's not just cancer patients who Have the need for medical services non coronavirus medical services treatment diagnosis, what have you I mean if you if if something is bothering you You don't know exactly what it is. It could be anything And so query should you go to the doctor maybe hold back And if you find out what it is query whether you should you know pursue some sort of treatment or not Then it seems to me I want to throw an idea at you is that all of this is sort of intimidating It's intimidating for the patient because he doesn't want to go through an environment Like there's a case in Maui that was in the paper today about an elderly woman who went to the hospital And she had some unrelated problem completely unrelated problem And she wound up getting coronavirus in the hospital in Maui This is not so good So, you know, people are afraid to go into the medical world knowing that that's where coronavirus is being treated and therefore That's where there's a risk So I'm wondering the you know, how important testing is in that context and You know, pp. What is it ff ffe? um Sorry I'm not going to medical school anytime soon But I wonder how we didn't talk about ppe very much until until this anyway, I mean we knew what it was but it wasn't It wasn't like we used the The abbreviation every day now now we all know Anyway, so I'm wondering, you know, that becomes a kind of important thing not necessarily Limited to protecting people but to give them confidence that if you go into a medical facility You know, it'll be okay that you know, this is a risk worth taking And that even if they don't know exactly what's wrong with them. It's okay to go see a doctor. It's okay to be Exposed that nurses technicians would have you for a routine what might be routine medical issues Um, so, you know, it seems to me if I was running a hospital I would say really got to get testing got to be sure everybody in the room or at least most people in the room Who are at risk of having it of you know being able to shed virus? um They're they're they're tested and they're protected and everybody else is protected And short of the PPE and the testing, you know, you you can't have a hundred percent Level of confidence about that So how important is that at least in your analysis? And and how important is our effort to get those things to our medical professionals here in Hawaii? well, I think as as a lot of people have been talking about in the news, uh testing is key uh to getting back to some level of normalcy Because you you want to be able to be sure That you're not infected and the people you're interacting with are not infected Really testing is going to have to be much more widespread It isn't available to that extent right at the moment And we don't really even have the clinical laboratory infrastructure set up to do The level of testing that would be optimal. I think I think we're fortunate in Hawaii at the moment we've had A quite a flattening of the curve as they say We've had a low number of cases that have been Diagnosed especially compared to many other areas of the country so I think that people can feel a little safer here, but At the moment everybody's going to be a little nervous about going to the doctor's office and going to the hospital because That's where sick people are going to be And that's always been the case. I mean for people who have children. They know that Going to the pediatrician's office. You knew in the waiting room You're going to be exposed a whole bunch of stuff that you probably didn't want to get exposed to just sitting there Just sitting in the waiting waiting room, but it wasn't it wasn't quite as uh Deadly uh as as this uh coronavirus so uh, so that's been uh It makes me wonder it makes me wonder You know, you know, how the how the physician industry Primary physician industry is doing these days Uh, this has got to have an it has an effect on every element of our society But query what kind of effect does it have on practicing doctors? Um, how are they how are they dealing with it? And how is it changing their their practices? I think we're going to be doing a lot more telemedicine I think the structure of our offices is going to change As as you know, you go to the doctor's office You're usually sitting in a room with a whole bunch of other people and There's no way that you can do social distancing In the in that sort of situation. So I I think a lot of things are going to structurally change and it's going to affect the medical Community as well One of the things I know we talked a little bit before we went on air that That has really affected us And we know it's going to affect us moving forward is Our clinical research and clinical trials for cancer patients This is the way that we find new treatments for patients And the re one of the reasons that we've seen a decrease in mortality from cancer over the last decade Is because we've developed better therapies for patients. Some of it has to do with earlier detection Some of it has to do with prevention But a lot of it has to do with treatment as well And we find new treatments by doing clinical trials You've heard a lot about clinical trials for things related to covet 19 It's it's in every press conference, you know, we're doing a clinical trial for this a clinical trial for vaccines You do the clinical trials because without the clinical trials You cannot figure out if something is effective and safe for patients And for cancer patients, it's really the same. We have to do these trials. Otherwise, we can't Advance therapy the therapy we give to people today is wholly different from what we gave 10 years ago And the reason is because we did clinical trials. We found out what was better We replaced the old stuff with the new better stuff. That's basically what we do We want to continue to do that during this pandemic Our clinical research efforts have really taken a hit. It's been very difficult To keep our studies up and going It's hard to enroll patients onto studies because everybody's focused on this other threat And I don't I don't blame them for that and we've had to cut way back on Our access to clinical trials trying to make those that are Particularly important for treatment of patients available But a lot of the other trials that we do are supportive care treatments developing new anti nausea medications some Prevention studies sleeping the hypnotic sleeping medications that Anything like that. We've had to put most of those on hold And that's been really difficult. It's it's happened across the country We have conference calls with our other nci designated cancer centers At least twice a week to discuss what we do about clinical research how we can make it available to our patients Whether we can do things by telemedicine Whether we can consent patients for trials without having them come into an office and sign a Consent form we can do that over the phone or over a video These are all things that are completely changing and I think are going to change How we do clinical research for cancer patients and other patients Moving forward. So it's been a real impact on us. It's made it difficult and we have to also think about Our staff which are usually not Healthcare providers our clinical research associates who do data management on trials They we have to make sure that they're safe. Also when they go to to an environment In the hospital and take care of patients and interact with them Yeah, do you think you think that research should include tracking or is tracking something that doesn't require any medical training is just fact-finding Uh tracking doesn't I think it doesn't necessarily require medical training And so uh, some of the people in the department of health who are doing epidemiology tracking I think they're they're they're uh, lay people. They aren't uh, medical professionals Okay, I just I wanted to um, ask you about, um The effect on uh, on research funding So we have we have 2.3 trillion Plus another four or five hundred billion Coming down from the federal government Are your research programs at Japson or the cancer researchers? center seeing any of that money Not at the moment. Nothing that's been allocated is going to be going to Uh, to research except for research specifically for uh, COVID-19 which is certainly understandable I think from a cancer point of view, uh, we've actually Are very concerned uh, because A lot of the way we get funding is through foundations like the american cancer society The v foundation stand up to cancer a lot of these organizations have seen a drop In donations and some of them have actually Cancelled their grant programs. So we're a little concerned about that We're also concerned, uh, here at the university of Hawaii cancer center because we're a state institution We get support from the state and we know the state's going to have a big budget Uh deficit coming up because of the impact of this on the travel industry And so that means that the university is likely to see a significant budget impact as well That's going to affect, uh, how well we can do cancer research here at the cancer center And the reason I think that's so important is because the research we do is specifically targeted Toward reducing the burden of cancer for the people of hawaii for the populations We have here for the specific kinds of cancer that we have here And so if we aren't doing this research here, it's not going to be done elsewhere. So We really, uh, are a little concerned about the climate for funding For cancer research moving forward I know that in 2008 after the recession Some money went to the national institutes of health and the national cancer institute That provided some funding broadly for lots of different diseases I don't know if there are any plans to do that at the moment I hope so because uh funding research actually Is a great thing for helping the economy recover Because research funding leads to good jobs which leads to people buying, uh Groceries and going to restaurants and paying taxes. So Research funding is a good way to diversify the economy. So I'll put that in as a plug That we need to have good research funding for cancer research. It'll help the state overall I remember Ed Cadman's dream as he built the medical school 20 years ago And he had this this dream of big pharma with these large research facilities all around the medical school Unfortunately, it hasn't been been realized, but that doesn't make it less important We do bring in a lot of a lot of money. We bring in about 50 million dollars a year in Federal money to support research and most of that goes to paying for people who are Have good jobs here in Hawaii. So it does help One last question before we break, uh, Randall. Um, there's been so much talk about drugs that are Repurposed drugs drugs that have no clinical trial background and and you can see watching, uh, you know Donald Trump's press conferences that you can just see it on the television. They don't all agree and uh, some You know people Fauci for example, you know, you can see from his body language and from his remarks That's not a good idea and and and then you hear other doctors who have left the federal government They tell you in no uncertain terms. It's not a good idea So, you know for a person who has been tested positive and all that who is worried about it What how should he deal with this or she? Um, you know, because it's very threatening and, uh, and maybe Through a kind of black market mechanism Uh, a friend of a friend who knows what he can get a whole he can get a whole of, uh, Hydroxychloroquine and uh, maybe that'll help him even save his life Daniel Day Kim the the movie actor made a big video about that saying that it saved his life How do I deal with that or or do I say wait a minute medical protocols should prevail here? Let's not take silly chances. What's your thought? I put it in three words science saves lives So we should focus on the science And not just focus on anecdotes About what might help I think all of these things that people have talked about. Oh, this may be useful. This this might be useful They're being tested in studies. There was a recent study from the va with hydroxychloroquine It actually looks so good people who got hydroxychloroquine did worse than people who didn't This is why you need to do studies and you need to focus on the real data and the real science Behind it. I think that it's not bad to repurpose drugs repurposing drugs is a great idea but you have to do it in a Constructive way and it's best to do it with a scientific foundation Randall holicom holicom of the cancer research center In chapsum right here in hawaii doing world-class work. Thank you so much Randall. Great to talk to you today. Thank you